Pre-certification requirements

[jstaker]

What is the name of your state (only U.S. law)? Ohio.

This past March 2009 my husband was scheduled to have a CAT scan done. The doctor's office proceeded to get it pre-certified and had it done so but with his previous employment-related insurance company, on insurance that was terminated 12/31/08 because the employer chose to change companies due to cost!! His current employer-sponsored insurance company, in effect since 1/1/09 has refused to honor any of the pre-cert that was done and now he is being billed for the charge in full! What recourse does he have against the former insurance company who gave full authorization/pre-certification for the procedure? What are his options and to whom should he turn? Your help is deeply appreciated. Thank you.

[ecmst12]

Pre authorization ONLY addresses necessity guidelines, it does NOT address coverage. It was your husband's responsibility to make sure the CORRECT plan approved the service prior to receiving the services. It was ALSO his responsibility to make sure his doctor's office had the correct insurance information to do the right authorization. He has no recourse against ANYONE. If he did not make sure the auth was done correctly by the correct company, then he will have to pay for the procedure.

He can of course attempt to appeal the denial by the current insurance company, but since he did not correctly follow the rules of the plan, they have no obligation to pay the charges. They may do so as a courtesy, since he was new to the plan, if his condition is such that the plan WOULD have given the auth had it been correctly requested. That is going to be his best chance. His prior plan has absolutely zero obligation to pay for anything once the coverage is terminated.

[lkc15507]

Originally Posted by ecmst12

Pre authorization ONLY addresses necessity guidelines, it does NOT address coverage. It was your husband's responsibility to make sure the CORRECT plan approved the service prior to receiving the services. It was ALSO his responsibility to make sure his doctor's office had the correct insurance information to do the right authorization. He has no recourse against ANYONE. If he did not make sure the auth was done correctly by the correct company, then he will have to pay for the procedure.

He can of course attempt to appeal the denial by the current insurance company, but since he did not correctly follow the rules of the plan, they have no obligation to pay the charges. They may do so as a courtesy, since he was new to the plan, if his condition is such that the plan WOULD have given the auth had it been correctly requested. That is going to be his best chance. His prior plan has absolutely zero obligation to pay for anything once the coverage is terminated.

I kind of agree but disagree. Common misconception that plans that request or even require prior auth of certain services can / will DENY those services based upon the lack of the prior auth. I'll bet that one would find that the requirement for eligibilty of benefits the proof of medical necessity along with elig of the basic procedure (ie no specifc exclusions) are the first requiremnent. Seems to me we are talking about the requirements of Pre vs Post service claims here. Prior auth doesn't mean no auth. I agree penalaties etc may apply, but prior auth or none, by either plan, does not mean no bene.

[ecmst12]

1. This thread has been inactive for almost a month.

2. Your post makes no sense. Of COURSE a plan can deny a service that required preauth when preauth was not obtained. WILL they deny it all the time, who knows, that's why I suggested appeal. But it's not a question of CAN it be denied, of course it can, that's why the requirement exists!