Services Offered
- Revenue Cycle Management – CPT and ICD-9 (ICD-10) Coding
- Claims Denial Management and Reporting
- Credentialing & Contracting Services
- Insurance and Patient Collection Solutions
- Contracting and Credentialing Services
- Practice Management Implementation and Training
- EHR Implementation and Training
Pre-authorization and predetermination are processes that, if done correctly, can result in faster treatment and reimbursement optimization
Pre-authorization is the process by which a patient is preapproved for coverage of a specific medical procedure or prescription drug. Health insurance companies may require that patients meet certain criteria before they will extend coverage for some radiation oncology procedures, surgeries or for certain drugs. In order to pre-approve such a drug or service, the insurance company will generally require that the patient’s doctor submit notes and/or lab results documenting the patient’s condition and treatment history.
Pre-authorization does not guarantee reimbursement of services; however, the lack of pre-authorization could result in non-reimbursement. The process could take from five to thirty days and varies by health plan. When pre-authorization is obtained from a payer, a number is issued. The pre-authorization number is required on the claim upon submission to avoid unnecessary denials. If the claim is denied due to lack of medical necessity, providers should append the pre-authorization number when writing an appeal letter.
- See more at: http://periopradonc.com/difference-between-pre-authorization-predetermination/#sthash.HPSb0Jo4.dpuf
Predetermination can provide certainty to patients
Predetermination is similar to pre-authorization in that it allows services or treatment to be reviewed for medical necessity. May take a couple of weeks for determination. Any limitation under a plan can be addressed before services are provided.
A predetermination is a courtesy while pre-authorization is a requirement under a plan. However, when a payor recommends a predetermination for services, it is a good idea to do so. Most predetermination requests can take thirty to forty-five days and a complete history and physical of the patient should be included. If at any time the service(s) throughout a treatment course are denied, the predetermination can be submitted with the additional supporting documentation to help appeal the denial.