Given all the massive problems with enrollments not being done on time, I keep hearing "they can pay out of pocket and get reimbursed later." What about services that require pre-authorization? Anyone dealt with this?
What SHOULD happen: Physician calls carrier and gets pre-auth for procedure, at their location, under the plan the client is going to be enrolled in. They get a PA number, and include it in box 23 of the universal "CMS-1500 claim form".
If they don't get PA, it's handled like any other claim that doesn't have PA (doesn't really matter if the enrollment is complete or not). If they would've covered it, they'll probably cover it, but may deny just because it wasn't PA'd. If they normally wouldn't have authorized, they'll deny the claim.
Interesting post. I may be behind but this is my first time ever hearing of a CMS Form 1500. This is also the first time in my career that I’m dealing with applications missing in action. That would have never been tolerated by an agent in the past. Some companies said to have the client to go to an in network providers and pay out of pocket then submit a claim once their information arrives to the company. Another has something called a “Believe Me “ policy where the client can use services for free until their application is received and then they are billed according the terms of their policy.
I’ve never given much thought to the cases that need pre-authorization. So thanks dgoldenz for posting this and RayNY for your answer.
What SHOULD happen: Physician calls carrier and gets pre-auth for procedure, at their location, under the plan the client is going to be enrolled in. They get a PA number, and include it in box 23 of the universal "CMS-1500 claim form".
If they don't get PA, it's handled like any other claim that doesn't have PA (doesn't really matter if the enrollment is complete or not). If they would've covered it, they'll probably cover it, but may deny just because it wasn't PA'd. If they normally wouldn't have authorized, they'll deny the claim.
What actually happens is they call the insurance company and are told that they have no record of the person they are calling about....so what then? Nobody seems to be able to answer this question. The supervisor at UHC had no idea, same with H1.
UHC is the one that said go in network and pay out of pocket until they appear in the system. Once they appear in the system file your claims based on their saved receipts. It's a risk but the only answer I've received. I still have no shows from members submitted back in early November. My last UHC missing member showed up January 15th after two escalations.
Of course, if I specifically ask about pre-auth, I just get a shoulder shrug. Seems like no one knows for sure how they specifically address that in a situation where the member isn't in the system and never got pre-auth.
