Key points
- You cannot prevent every denial. Most avoidable ones come from a missing approval, the wrong network status, a limit nobody checked or a paperwork mismatch.
- Ask for approvals in writing, write down a reference number for every call, and keep copies of everything.
- Check each approval against the plan, the provider and the service before the care happens.
A denial costs time you may not have. Most of the steps below take a few minutes each and make a later appeal stronger, because you can show what you were told and when. None of them creates a new legal right. They help you use the rights and rules you already have.
What this means
Avoidable denials fall into a few groups: an approval was needed and not obtained, an approval was obtained for something other than what was done, the provider turned out to be out of network, a limit had been reached, or the claim was filed late or incorrectly. Each can be checked before care.
The steps below are practical habits. They do not replace your plan document or the rules that apply to your coverage.
What to do
Before non-emergency care
- Ask your doctor’s office whether prior authorization is needed. Ask who will request it and when. Ask for a copy of the request. (You and your doctor’s office.)
- Ask the plan the same question. Call the number on your card. Ask whether the service needs prior authorization and what the plan will look at. Write down the name of the person, the date, the time and the reference number. A call log keeps this together. (You.)
- Ask for the approval in writing. Ask for a letter, a portal message or a reference number you can look up. A verbal “it’s covered” is weak proof. (You.)
- Check the approval against the plan. Does it name the right service, the right provider and facility, the right dates and the right number of visits or days? If something differs, ask the office to correct it before the care. (You and your doctor’s office.)
- Confirm network status for every provider. That means the surgeon, the facility, the anesthesiologist, the lab and the radiologist. Ask the plan whether each is in network on the date of service. Save a dated copy of the directory page. If you relied on the plan’s directory and it was wrong, the plan may not charge you more than in-network cost sharing. (You.)
- Ask about limits. Ask how many visits, days or units the plan covers in a year and how many you have used. Ask what happens at the limit. (You.)
- Ask for a written estimate. The federal good faith estimate rules cover uninsured and self-pay patients. The matching rule for insured patients has not been put into effect, so you cannot demand one, but you can ask your provider. (You.)
- Read before you sign. If a provider asks you to sign a consent to out-of-network billing, read what it says. A valid waiver for covered services requires written notice and an estimate. Some services can never be waived. Original Medicare providers may hand you an Advance Beneficiary Notice of Noncoverage, which shifts potential liability to you. (You.)
For drugs
- Check the formulary each plan year and ask whether your drug needs prior authorization, step therapy or has quantity limits. A plan switch may restart them, so ask the new plan. Ask your prescriber to start any request early. (You and your prescriber.)
After care
- Compare the explanation of benefits with the bill and the approval. Check that they agree before you pay. Mismatches in dates, providers or codes are common. (You.)
- File claims on time. If you file yourself, check the plan’s filing window. (You.)
- Keep a folder. Keep approvals, letters, explanations of benefits, bills, receipts and the call log, in order by date. Keep them at least until the claim is final. (You.)
- Act on a denial at once. Note the appeal deadline on a calendar. The first 48 hours guide helps. Check the date on your notice, which controls. (You.)
What the plan may say, and what to say back
“Prior authorization is not required for that service.” Ask for that in writing, or for a reference number and the name of the person. Note the date and time.
“We cannot guarantee payment.” Ask what could change the decision, such as eligibility on the date of service, the provider’s network status or the codes used. Ask what you should check before the care.
The rule
A plan cannot deny a claim for lack of prior approval where getting approval was impossible or could seriously jeopardize life or health. 29 Code of Federal Regulations (CFR) 2560.503-1
Watch for
- Emergencies. Do not delay emergency care to collect approvals. If your plan covers emergency department services at all, emergency services must be covered without prior authorization.
- Rules differ by plan. The deadlines and rights above vary with your coverage. Find out which kind you have: see the guide on finding your plan type.
- Approvals expire. Ask how long an approval lasts and what happens if the date of care moves.
- Records. Keep copies of what you send. Keep proof of the date.
What next
- Prior authorization denied: what to do if a request is refused.
- Approved, then denied: if the plan approves and then refuses to pay.
- Keep a call log: the record that backs up every call.
- Good faith estimates: when you are owed an estimate and when you can ask for one.