So a health plan has denied your preauthorization request for a patient’s treatment. What options do you have?
First determine the patient’s type of coverage.
Medicare Advantage plans have specific appeal guidelines, which you can find on the Centers for Medicare & Medicaid Services website. Be sure to check out the appeals flowchart. Commercial health plans also post specific appeal guidelines on their websites, typically as part of their provider manual. Before providing a service, you should always check to see if the health plan has a preauthorization requirement.
In 2013, as a result of hard work by TMA, the Texas Legislature passed bills requiring health plans to accept a standardized prior authorization form for medical services and for prescription drug benefits. The legislation also addressed preauthorization by HMOs and preferred provider benefit plans, which must respond to physician and provider to preauthorization requests within specific time frames, and written procedures for appeal when a preauthorization request is denied.
In 1997, the Texas Legislature made Texas the first state to require a system of independent review of insurer decisions by reviewers who do not work for the insurance company or HMO. Use of an Independent Review Organization usually is permitted only after patients have completed the insurer’s internal appeals process.
If you believe a health plan is not complying with any one of these requirements, you may file a complaint with TDI. Patients may also file complaints regarding their health plan and should be encouraged to do so.
When you have questions about billing or payer policies, contact TMA’s reimbursement specialists for help at paymentadvocacy[at]texmed[dot]org, or call the TMA Knowledge Center at (800) 880-7955. TMA members can use TMA’s Reimbursement Review and Resolution Service (formerly known as the Hassle Factor Log program) to help resolve insurance-related problems. Visit www.texmed.org/GetPaid for more resources and information.
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Last Updated On
July 25, 2023
Originally Published On
April 13, 2017