NO AUTHORIZATION SCENARIO IN MEDICAL BILLING : DENIAL MANAGEMENT : AUTHORIZATION REQUIRED

#AUTHORIZATION REQUIRED SCENARIO IN MEDICAL BILLING
#AUTHORIZATION: An approval requested (by doctor) from insurance/payer.
#PRE or PRIOR AUTHORIZATION : An authorization obtained from insurance before treatment.
#RETRO AUTHORIZATION: An authorization requested from insurance after treatment done.
#PRE ANALYSIS ON DENIED MEDICAL CLAIM: While we working medical claim we need to check from our whether we have authorization number in our billing software or not. If we authorization then verify with insurance representative whether it is valid auth or not. If auth# is valid, request claim for reprocess and if authorization is not valid, appeal with complete medical records. if in further appeal upheld, adjust the claim balance as no authorization found.
#We have to check all possibilities to get authorization on previous date of services rendered.
#EMERGENCY SERVICE DOES NOT REQUIRE AUTHORIZATION
#PLACE OF SERVICE 23 or EMERGENCY ROOM SERVICES does not require any authorization.
#Simple here insurance trying to deny the payments but as AR associate we should try to get the payments to the doctor or provider or physician.
#DENIAL MANAGEMENT
#PRE AUTH
#RETRO AUTH
#AR IN HEALTHCARE IN MEDICAL BILLING.
NO AUTHORIZATION SCENARIO DETAIL INFORMATION.
WHAT IS AUTHORIZATION.
WHAT IS PRE AUTH.
WHAT IS RETRO AUTH.
WHAT IS INPATIENT
#Reason for invalid authorizations:
AUTH IS NOT VALID FOR DATE OF SERVICES,
AUTH IS EXCEEDS THE DATES,
AUTH IS INVALID BECAUSE PROVIDER NAME LISTED ON AUTHORIZATION WAS NOT SAME ON BILLED CLAIM or FILED CLAIM.
AUTH IS NOT VALID FOR BILLED TAX ID means is valid on diff tax id.
AUTH IS DISALLOWED FOR INPATIENT STAY BECAUSE SERVICE WERE RENDERED AT LOWER LEVEL OF CARE that is SAME DAY SURGERY or ONE DAY SURGERY or Ambulatory surgical center.
AUTH IS DISALLOWED BECAUSE NOT BEEN MEDICALLY NECESSARY FOR INAPTIENT SERVICE RENDERED.
CLAIM DENIED FOR AUTHORIZATION BECAUSE LISTED AUTHORIZATION NUMBER IS NOT AUTH BECAUSE IT IS REFFERAL.
#WHAT KIND OF SERVICES REQUIRED AUTHORIZATION:
Inpatient services required authorization.
MRI scan codes required authorization.
Cardiology services required authorization.
Keep in mind that HIGH DOLLOR claims generally required authorization.
#AUTH.

[@AshleyPratap]

Thanks for sharing this , it really clear a lot!

[@PKRVibesCareerGrowth]

Thanks Ashley Pratap

[@SajjidIshaq]

​@@PKRVibesCareerGrowth😊

[@manikantawaddi9747]

Bayya u r awesome Thanks for u r videos

[@PKRVibesCareerGrowth]

Welcome you

[@nancyjesu9825]

Really superb. In one video you covered all scenarios. I easily understand thank you so much.

[@PKRVibesCareerGrowth]

Welcome you nancyjesu

[@nancyjesu9825]

If I watched your video's previously, i would answered my interviewer questions 🥹

[@nancyjesu9825]

@@PKRVibesCareerGrowth Thank you so much. 🤝

[@manikyaraogogumalla8903]

Fabulous explanation sir , tq so much

[@PKRVibesCareerGrowth]

Welcome you

[@parthasarathyvenkatachari2617]

@@PKRVibesCareerGrowth sir one doubt retro auth used for emergency purpose since failed to get prior approval but since we have pos 23 emergency then do we need retro auth? pls clarify

[@PKRVibesCareerGrowth]

@@parthasarathyvenkatachari2617 please note that if POS 23 there on claim form, it is not required to obtaining pre or retro Authorization. So if claims denied, as a AR caller, probe the same and request to reprocess the claims over the phone calls 📞 itself 😊

[@beautychaudhary1]

Thank you sir❤ for really help me I understand this scenario now❤

[@PKRVibesCareerGrowth]

@@beautychaudhary1 welcome you and thank you for watching the video

[@VijayHephzibah-wf2mp]

Thank You so much, well explained

[@PKRVibesCareerGrowth]

Welcome you Vijay

[@amarshrivastav4473]

Need more scenario like no claim on file, maximum benefits met, denied for duplicate, claims paid, claim in process, etc.

[@PKRVibesCareerGrowth]

Sure Amar. Max I will cover all scenarios

[@amarshrivastav4473]

@@PKRVibesCareerGrowth thank you

[@AshleyPratap]

Yes need these cases too

[@PKRVibesCareerGrowth]

Sure@@AshleyPratap

[@malikasif1615]

And what is your designation in medical billing

[@rjshetty9964]

Thankyou so so much

[@PKRVibesCareerGrowth]

Welcome you

[@tufailansari3075]

Thank you so much sir

[@PKRVibesCareerGrowth]

Welcome you.

[@SanjeevKumar-ev1dl]

Great information thanks sir

[@PKRVibesCareerGrowth]

Welcome you

[@kotaharish4286]

Valuable information 😊

[@ashtonmartin8635]

Sir, you have explained this scenario, but I do have some doubts. In some cases, rep refuses to take up the claim, even though the auth no# is valid for the DOS. If that's the case should be get a new auth no and send a corrected claim or appeal the claim. If the TFL has expired for sending corrected claim has expired, do we need to need to work for TFL denial or directly file an appeal if we are sure the claim will deny for TFL. My next question, name some insurances which accepts retro authorization. If rep says retro authorization is possible and tells the procedure to obtain retro auth, may I know who is responsible to get retro auth, is the AR caller himself or move to client review. My next scenario we are to obtain retro authorization, but the TFL is going to expire in another 2 days, then what's the procedure for that?

[@PKRVibesCareerGrowth]

On high priority, again reach another insurance rep, probe that already we have valid auth#, so request for reprocess the claim over the phone call. If rep refused to reprocessing claim(means available auth not valid), so you can go for appeal with attached denied eob(acts as POTFL), MR. As a AR caller generally for recent DOS you can obtain retro auth from payer.

[@PKRVibesCareerGrowth]

1st you call n reprocess . 2. If not reprocess , appeal with denied eob n MR. 3. If dos is recent , you can obtain retro. 4. If tfl expire ,then follow TFL workflow

[@SumitKumar-xp1sg]

Very helpful 🥺thanku

[@PKRVibesCareerGrowth]

Welcome you Sumit

[@ayyappagowdabiradar471]

what kind special office visits need authorization

[@PKRVibesCareerGrowth]

Hi Ayyappa...All High dollars Office/inpatient services and Office Hospital based out patient services (example : Oxygen treatment) need authorization.

[@SagarSingh-ty4gj]

Please make a video on how to send primary EOB claim denied for missing eob

[@PKRVibesCareerGrowth]

Sure I will make 👍

[@Chaiaurchutney]

What if the claim Is denied for no auth by Medicare for e and m code in this case what we would do?

[@PKRVibesCareerGrowth]

Hello Dinesh. Traditional Medicare will deny for no auth is very Rare. For E&M codes on 1st visit(New Pt ) no auth required. For follow up visits (established pt's visits ) auth will require is in rare condition s. You have to call traditional Medicare Representative and obtain further procedure accordingly.

[@malikasif1615]

In which company you working

[@lifeisgoddhevudejeevitham]

which services doesn't require AUTHORIZATION ?

[@PKRVibesCareerGrowth]

Emergency services, Routine services, small dollar services and out patient services are doesn't require Authorization.

[@balapadma7293]

per auth is not timely means?

[@pramodkumarneralla140]

Tq bro

[@PKRVibesCareerGrowth]

My pleasure brother.

[@alekhyap1388]

Explain about clia and ndc

[@PKRVibesCareerGrowth]

Good suggestion 👍. In sooner, I'll make a video on CLIA , LCD & NDC (Non covered related).

[@HariPrasad-lm3fe]

Could you please explain about how to appeal with medical records and fax or mailing address

[@PKRVibesCareerGrowth]

Sure

[@motherworld8883]

Sir I want to take some personal training from you can you give me

[@PKRVibesCareerGrowth]

Ping me at [e-mail]

[@lolololol5071]

sir if the service already rendered and provider got an auth from the secondary and not the primary and claim denied by primary for no auth. Cant ask for retro auth because past TFL, what should be done?

[@PKRVibesCareerGrowth]

Since TFL expired don’t go for Retro. Good to Go on appealing

[@lolololol5071]

@@PKRVibesCareerGrowth thank you sir, i have one more question where can i get the appeal form for humana and cigna? what can i do to appeal if i cant find any?

[@vuthurivenkatesh3236]

Sir Do you have any proper notes about RCM please share

[@PKRVibesCareerGrowth]

Hi Venkatesh. Please ping me at [e-mail].

[@rockingstressbusters3026]

Sir please can u tell us that what steps we need to follow in brightree and acue to every claim deniels .
Like if no auth then in the software where we can check etc.🙏

[@PKRVibesCareerGrowth]

Welcome you. You have to check/explore the providers services and details on your internal doctor's billing software for auth#. Also open pink CMS 1500 claim form and verify does claim billed with Auth# on Box#23.

[@rockingstressbusters3026]

@@PKRVibesCareerGrowth sir i can't able to fine what we need to check stuff to verify that denial is correct or not can u please made a vedios on that with every denial it will very helpful for me please 🙏

[@PKRVibesCareerGrowth]

@@rockingstressbusters3026 sure

[@rockingstressbusters3026]

@@PKRVibesCareerGrowth thanks sir my training period is just near to end please made vedios that I can learn before my training complete thank u so much

[@PKRVibesCareerGrowth]

What denials you looking for ?

[@user-mv1ig3og8y]

Hi bro kindly provide how to work for n286 referring doctor primary identifier

[@PKRVibesCareerGrowth]

Hello bro ..are u sure is referring doctor or Rendering Provider?

[@Cricketmother]

What happened when patients authorization fails? Plzreply

[@PKRVibesCareerGrowth]

As a AR Caller, you need to call payer and need to get the exact reason as why auth failed ?. Based on Medical records (Treatment or service given to patient) if you felt that the billed auth is valid, then good to go for an appeal with complete MR and along with necessary documents.

[@Cricketmother]

​@@PKRVibesCareerGrowththank you sir

[@saicharanperla9244]

Sir u from telugu state?

[@PKRVibesCareerGrowth]

Yes Sai

[@saicharanperla9244]

@@PKRVibesCareerGrowth mi explanation chala bagundi sir

[@PKRVibesCareerGrowth]

@@saicharanperla9244 thank you for your support.