MYTH: MA Plans are not required to respond to an inpatient authorization request.
FACT: MA Plans ARE required to respond to an inpatient authorization request.
A large 11 hospital provider member recently submitted a complaint to ERN/TRAF against a health plan who failed to approve or disapprove authorization within one (1) hour of contact being made and denied the claim stating the provider had notified them 23 days after patient admission and instructed the provider to bill the claim with clinical documentation after patient discharge. This would have resulted in an immediate backend denial and delayed revenue capture through the reconsideration process.
In the first sixty-one (61) days the patient was in house, the health plan denied services that were rendered. On 11/29/2021, ERN/TRAF submitted a Summary of Complaint and notified the health plan that the complaint had been sent. On the next day, 11/30/2021, the health plan sent a notification of authorization for all dates of services concurrently as the patient was still hospitalized. With ERN’s help, an authorization was secured in just eight (8) days for all dates of service.
This post was written by ernncra