The payer says no prior authorisation was on file.
CO — Contractual obligation — the provider absorbs it and cannot bill the patient.
So the balance cannot move to the patient. Either the appeal recovers it or the practice absorbs it. That makes the appeal decision the whole decision on this line.
Usually recoverable. Appeal it. The money is usually there.
In the order we see it.
No authorisation was requested before the service.
An authorisation existed but had expired before the date of service.
The CPT billed does not match the CPT on the authorisation.
Authorisation was obtained under a different plan or payer than the one billed.
Request a retro-authorisation. Many payers allow one inside 30 to 90 days. If auth existed, appeal with the auth number and date.
The documentation, not the argument.
The authorisation number and its approval date.
The retro-authorisation request and the payer's response to it.
Documentation that the service was urgent or emergent, where the payer waives auth for those.
The common mistake. Do not appeal before checking whether a retro-authorisation window is still open. Retro-auth is faster, higher yield and does not spend the appeal.
Where this comes from. This is our own reading of the code, not the payer's and not a copy of the standards text. We classify it from how these denials actually resolve. Where we are unsure, we say so rather than guessing.
Send your denial summary for the last ninety days. Four columns: payer, CARC code, count, billed amount. I will tell you which were winnable and what they were worth.
Send your denial summary No patient data. No BAA. No charge.
AppealHound