What is Prior Authorization?
Prior authorization is almost always necessary for behavioral health treatment. Once your authorization team and your patient's insurance provider agree on they type of service and approximate length of time that the patient will require, the insurance representative will give you an authorization number.
Typically before a patient admits into your facility, your UR specialist and case manager should have already determined what type of care your patient needs based on medical necessity criteria. This helps eliminate confusion about what treatment the insurance company will allow and later, pay for.
If the provider is unable to get authorization before treatment begins, they have to request a retroactive authorization. Insurance companies are not legally obligated to pay claims that do not follow their guidelines making it much more difficult to get a claim paid if there is not an authorization on file before treatment begins..
Click here to learn more about prior authorization.
Use the following best practices to prevent authorization delays:
Keep Facility Licenses and Accreditations Accessible
Payors like to view licenses and accreditations before authorizing treatment. The quicker you get them the information, the sooner you will get paid.
Review The Client’s Chart
Know the client's medical history before you contact the case manager. You should understand the severity of the patient's symptoms, his/her mental status, current medications, previous family therapy notes, etc. The more you know, the more treatment you will get authorized. ASAM guidelines are a great tool for obtaining authorization.
Check for Typos
It is critical that all information concerning the patient and facility are input correctly. One small typo will cause the claim to deny. If you are lucky, the insurance company will tell you the information is incorrect. Most likely, it will take numerous phone calls from a claims management specialist before the issue is resolved.
Call In The Case ASAP
If you miss the deadline, you risk treating a patient and later being denied authorization
Errors happen. Cover your bases by noting the date and time of all insurance phone calls, the name of the case manager that you spoke with, the services and codes they approve and of course, the authorization number.