Meritain Prior Authorization List (2024)

FAQs

Why do prior authorizations get denied? ›

If a provider's office submits a wrong billing code, misspells a name or makes another clerical error, this can result in a denied PA request. This is common for procedures like cosmetic surgery or treatments not approved by the FDA.

If prior authorization is required and is not obtained, the health plan can reject the claim—even if the procedure was medically necessary and would otherwise have been covered.

How long does prior authorization take? The review typically takes about 14 days. Then, we'll update you and your doctor with a decision.

The proper response to a failure to obtain preauthorization denial is to request a retrospective review. This type of review occurs after the medical service has been provided, and it involves the insurance company evaluating the claim to determine if it meets the necessary criteria for coverage.

Delayed Access To Treatments

But even when you're confident that you need to get pre-authorization, the manual process for your practice staff takes time. And because the forms and details regularly change as well, this often leads to delays. You might be able to obtain prior authorization within 24 hours.

Ways to improve prior authorization in California include requiring payers to use automated systems for prior authorizations and limiting how often prior authorization is needed for ongoing treatments.

The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patient's insurance provider.

If I go see a doctor, can that doctor see my medical records from another doctor? It depends. If the new doctor is not part of the network of you previous physician, you must send record or give the new doctor access. If the matter concerns certain classes of medication, there is a database.

What is the reasoning behind prior authorization requirements? ›

Summary. Prior authorization criteria are based on scientific evidence, standards of practice, peer-reviewed medical literature, established clinical practice guidelines, as well as safety and efficacy data. The goal of prior authorizations is not to create undue burden on patients or to intentionally prevent access.

On average, practices complete 45 prior authorization requests per physician, per week. Physicians and their staff spend an average of 14 hours—almost two business days—completing those requests each week. 35% of physicians have staff who work exclusively on prior authorizations.

A CT scan can be denied by your insurance company for a variety of reasons. The simplest reason is that you may have filled out a form wrong or left off the necessary information. Your doctor's office could have miscoded the procedure or failed to provide certain information.

Medical Necessity

Aetna considers magnetic resonance imaging (MRI) medically necessary for appropriate indications without regard to the field strength or configuration of the MRI unit. Aetna considers intermediate and low field strength MRI units to be an acceptable alternative to standard full strength MRI units.

Insurance companies sometimes deny prior authorizations. They often will not approve a non-formulary product unless: A person has already tried their plan's preferred products. A person has an intolerance or contraindication to the preferred products.

A pre-auth error can occur for a few different reasons: Your credit card may be over its limit. If you're using a debit card, you may have insufficient funds in your account. Your card may have expired. Your bank may have activated fraud protection.

Adjudicating is the process of contacting your insurance company to determine whether the claim for the medication will be paid or denied. In the case of a prior authorization, this means the insurance company rejects the claim saying it requires a prior authorization.