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Getting Authorization
- Post starter qwyoey
- Start date
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Friday
Sponsor
It used to be part of my job.
BLUF (bottom line up front) Have your clinic do it.
There's always fine print associated with every clause & proviso in an insurance document. Essentially every single number or statement on the patient information sheets? Has between 1-5 paragraphs attached to it in the actual policy. What you'll want to request is a copy of the actual policy. If the copy you have is less than about 100 pages (could be as little as 50 up to several hundred pages) in very very fine print? You have the abbreviated version.
Working with a TaxID (aka medical professional request), it generally took me between 24 & 72 hours to get the relevant documents from the insurance company. As a policy holder? 6-12 weeks. And then I t was usually he wrong info, and I had to submit another request. Insurance companies draaaaaag their feet in sending useful information. So DO try and 1) get your therapists office to get preauthorization for you (it's much faster... and easier, since they're the ones doing it ;)), or 2) Don't ask. But instead download a copy of the whole f*cking thing yourself from online, if you have access. ((Insurance companies are pretty notorious for removing patient access to their policy once they start challenging it.))
Once you have your actual policy in front of you there are 2 places you want to look: the obvious (psych benefits) & the sneaky (outpatient benefits).
In both places there will usually be adjusted rates & numbers & maxes for continuing past the allocated number of visits per anum. You'll want to highlight the paragraphs that relate to what you're looking for, including the billing codes, and form ID numbers (because every possible request has a specific form). That form will have to be filled out by your healthcare provider, or they'll need to give you the info so you can bill your insurance yourself (TaxID numbers, provider ID numbers, etc.).
So first you fax/email the preauthorization form, (don't mail it) with all the info. Then they usually deny it, proforma, and you submit an appeal (different set of forms), and they either accept it (usually the case, the denial is just to make policy holders think the actual answer is "no", while professionals just resubmit everything, because the "no" is meaningless).
Professionally, that whole process takes about a week.
As a policy holder? It's generally about 6-9 months. Unless I've got access to OneHealthPort and a few other databases I can attach reference IDs to bully them with. In which case it's about 1 month.
Really... Have your clinician's secretary do it.
BLUF (bottom line up front) Have your clinic do it.
There's always fine print associated with every clause & proviso in an insurance document. Essentially every single number or statement on the patient information sheets? Has between 1-5 paragraphs attached to it in the actual policy. What you'll want to request is a copy of the actual policy. If the copy you have is less than about 100 pages (could be as little as 50 up to several hundred pages) in very very fine print? You have the abbreviated version.
Working with a TaxID (aka medical professional request), it generally took me between 24 & 72 hours to get the relevant documents from the insurance company. As a policy holder? 6-12 weeks. And then I t was usually he wrong info, and I had to submit another request. Insurance companies draaaaaag their feet in sending useful information. So DO try and 1) get your therapists office to get preauthorization for you (it's much faster... and easier, since they're the ones doing it ;)), or 2) Don't ask. But instead download a copy of the whole f*cking thing yourself from online, if you have access. ((Insurance companies are pretty notorious for removing patient access to their policy once they start challenging it.))
Once you have your actual policy in front of you there are 2 places you want to look: the obvious (psych benefits) & the sneaky (outpatient benefits).
In both places there will usually be adjusted rates & numbers & maxes for continuing past the allocated number of visits per anum. You'll want to highlight the paragraphs that relate to what you're looking for, including the billing codes, and form ID numbers (because every possible request has a specific form). That form will have to be filled out by your healthcare provider, or they'll need to give you the info so you can bill your insurance yourself (TaxID numbers, provider ID numbers, etc.).
So first you fax/email the preauthorization form, (don't mail it) with all the info. Then they usually deny it, proforma, and you submit an appeal (different set of forms), and they either accept it (usually the case, the denial is just to make policy holders think the actual answer is "no", while professionals just resubmit everything, because the "no" is meaningless).
Professionally, that whole process takes about a week.
As a policy holder? It's generally about 6-9 months. Unless I've got access to OneHealthPort and a few other databases I can attach reference IDs to bully them with. In which case it's about 1 month.
Really... Have your clinician's secretary do it.
- Post starter
- #3
Wow- thank you for the fantastic reply. Honestly growing up without any adult support has left this huge black hole in understanding how a lot of things work- like insurance.
The whole thing horrifies me.
Generally speaking, do you know if they have to get authorization per appointment after each visit or will they pre-authorize a certain number again? I know in some states I read they can no longer do this. Sadly I'm not in one of those.
The whole thing horrifies me.
Generally speaking, do you know if they have to get authorization per appointment after each visit or will they pre-authorize a certain number again? I know in some states I read they can no longer do this. Sadly I'm not in one of those.
Friday
Sponsor
I was about to come back and apologize for typing before coffee. Aka Waaaay too many words.
There are about a dozen different pathways to getting what you want (aka more covered appointments). It all depends on your individual policy. It could be very simple, if your policy just flat out lists after 24 visits, will cover 60%, for example. Or with an Rx will cover at 100%. It could be really complicated, with appeals and other nonsense. Basically, the very first step is to see if it's simple, and if not ask if your provider will do this for you. If they already bill your insurance for you? They'll probably tackle this, also. It's not very different, from an admin perspective. We used to do it all the time, with about 500 active policies in play any given week, there were a couple dozen a week that we would be dancing this game of "pony up". If they won't (and if they don't have a secretary or billing department, it's about 20 hours of work all told, which means solo practitioners just don't have the time to handle insurance tangles), then there are some step by step guides that will make more sense than my rough outlines. Battling insurance companies for patient benefits is actually a whole job, with a wicked steep learning curve. Is it something you can learn to do on your own? Absolutely. Patients and families do, all the time. Especially with long term illness. But if you can get someone else to do it for you? All the better.
Step 1 : Look at your policy (abbreviated) and see if it's really simple. 24 visits per anum at this rate. All others at this other rate.
Step 2 : Not simple? Ask your provider to do it for you.
Step 3 : If they won't? Look up the step by step guides for your individual insurance plan & how to best apply / submit / appeal / etc.
There are about a dozen different pathways to getting what you want (aka more covered appointments). It all depends on your individual policy. It could be very simple, if your policy just flat out lists after 24 visits, will cover 60%, for example. Or with an Rx will cover at 100%. It could be really complicated, with appeals and other nonsense. Basically, the very first step is to see if it's simple, and if not ask if your provider will do this for you. If they already bill your insurance for you? They'll probably tackle this, also. It's not very different, from an admin perspective. We used to do it all the time, with about 500 active policies in play any given week, there were a couple dozen a week that we would be dancing this game of "pony up". If they won't (and if they don't have a secretary or billing department, it's about 20 hours of work all told, which means solo practitioners just don't have the time to handle insurance tangles), then there are some step by step guides that will make more sense than my rough outlines. Battling insurance companies for patient benefits is actually a whole job, with a wicked steep learning curve. Is it something you can learn to do on your own? Absolutely. Patients and families do, all the time. Especially with long term illness. But if you can get someone else to do it for you? All the better.
Step 1 : Look at your policy (abbreviated) and see if it's really simple. 24 visits per anum at this rate. All others at this other rate.
Step 2 : Not simple? Ask your provider to do it for you.
Step 3 : If they won't? Look up the step by step guides for your individual insurance plan & how to best apply / submit / appeal / etc.
VioletButterfly
Diamond Member
I agree with letting your provider handle this as he/she and the carrier speak the same language. It could just be a matter of the provider calling the carrier to request an extension and then following up with paperwork. Do give yourself and the provider as much lead time as you can. And, always appeal should you need to. Four good rules when dealing with insurance carriers: always confirm benefits before going to an appointment, document/document/document, escalate issues sooner rather than later when you don't get info you need from a CSR (work it up the food chain to a manager/director/VP), and always appeal should you need to. Also, know your rights as covered under federal and state law.
- Post starter
- #6
I'm glad this worked out for you! The words "prior authorization" will forever echo in my head - but that is a story for another time.
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