Access Support can help physicians obtain a prior authorization form when one is required by the patient's health plan.
Some health insurers require that a prior authorization be issued before certain items or services are covered. A Prior Authorization is used by many commercial health insurers, managed care organizations (including Medicare Advantage Plans), and other health insurers to determine medical necessity for a healthcare service prior to the time claims are considered for coverage. When Prior Authorization is pursued prior to the time a service is rendered, it helps ensure that the patient understands coverage for the service before a financial obligation to the provider may be incurred. Health insurers may require a Prior Authorization as part of their coverage policy. Failure to obtain a prior authorization from some health insurers before service is rendered may cause a claim to be denied coverage, despite the fact that the claim would have otherwise been covered.
Some insurers will make a predetermination of coverage decision upon request. A predetermination generally applies to an item or service for which the health insurer does not require a prior authorization. If, after providing a predetermination decision, the health insurer indicates that the item or service will be denied coverage, the physician or patient can appeal the decision.
Prior Authorization Appeals
Physicians and patients can appeal an insurer's decision to deny a prior authorization. Many states mandate that insurers maintain coverage appeal processes, including an expedited process that must be completed within a relatively short period of time (e.g., 72 hours). Preparation for the appeal of a denied prior authorization is much the same as preparation for the appeal of claims that are denied coverage, as discussed below.
Note: The Medicare program publishes Medicare coverage policies and claims are considered for coverage at the time they are presented for payment. Providers are responsible for understanding Medicare coverage policy and advising patients when a non-covered service is rendered (for services that are included within the scope of the Medicare program, such as chemotherapy). Before a Medicare beneficiary can be billed for a non-covered service that is within scope, the patient must sign an Advance Beneficiary Notice, or "ABN," acknowledging contingent financial responsibility (contingent upon non-coverage of the service by the Medicare program). Medicare beneficiaries should not be billed for non-covered services that are within scope unless the provider is in possession of a properly executed ABN Form pertaining to the billed service.
Health insurers may require specific forms and supporting documents before a Prior Authorization may be issued (ie, history and physicals, pathology reports, etc.).
Obtaining Prior Authorization: An Example Process Flow
The following algorithm illustrates the prior authorization assistance process through Access Support™ for infusible agents. Health insurers may require specific forms and supporting documents (e.g., history and physicals, pathology reports, etc.) for Prior Authorization.
Verify Patient Coverage.
Is your patient insured?
If patient is uninsured, or if they require additional reimbursement assistance, click here for available programs or refer them to a financial counselor.
If patient is uninsured, or if they require additional reimbursement assistance,
click here for available programs or refer them to a financial counselor.
Is Prior Authorization Required?
Was prior authorization received?
Prior authorization not required, click next to continue.
You now have payer authorization.
You now have payer authorization.
Claim approved / patient received medication.
The accurate completion of reimbursement- or coverage-related documentation is the responsibility of the healthcare provider and patient. Bristol-Myers Squibb and its agents make no guarantee regarding reimbursement for any service or item.
This process flow serves as an aid to understanding the reimbursement and appeals processes. Please consult a beneficiary's insurer regarding coverage policies.
Note: Medicare Part B publishes national and local coverage policies,1 and considers claims for coverage only at the time providers present them to a Medicare Administrative Contractor for payment.
Providers must understand Medicare coverage policy.
If original Medicare denies a service as "not reasonable and necessary," the provider may only bill the patient for the denied service if the provider obtained a signed Advance Beneficiary Notice (ABN) from the patient before the service was provided.
If a properly executed ABN has not been obtained, the provider may not bill the patient for the service denied as "not reasonable and necessary."
An ABN has been designed and approved by CMS for this purpose and is available on the CMS Website at http://www.cms.hhs.gov/BNI/02_ABN.asp.2 This form was created for Medicare Part B and does not apply to Medicare Advantage plans or Medicare Part D, which may have their own unique prior authorization and patient notification procedures.3
Medicare Rights Center. Medicare Part D appeals. http://www.medicarerights.org.
Accessed December 08, 2011.
Centers for Medicare & Medicaid Services. The Medicare Appeals Process.
http://www.cms.hhs.gov/MLNProducts/downloads/MedicareAppealsProcess.pdf. Accessed December 08, 2011.
Centers for Medicare & Medicaid Services. Medicare claims processing manual.
http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-%2099&sortByDID=1&sortOrder=ascending&itemID=CMS018912. Accessed December 08, 2011.