Healthcare providers are often required by insurance companies to get approval or permission before they can provide certain medical services. This step is taken to confirm that the treatment is medically necessary. Not all medical services need pre-authorization, but each insurance company will provide a list of services that require this step.

The Department of Utilization and Management Review within the Insurance Company will grant pre-authorization after reviewing the treatment plan submitted by the provider. There are exceptions for emergency cases. This step is also known as pre-certification.

Significance of Pre-Authorization: The role of the Insurance Verification team is crucial and lays the foundation for the pre-authorization process. This process helps to maximize revenue and ensures the proper collection of payments for healthcare services provided by the organization. Pre-authorization does not ensure payment, but if the claim is rejected, an appeal can be made using the authorization number for a possible claim settlement from the insurance company. The absence of pre-authorization can result in financial risks for both the patient and the healthcare provider. Therefore, partnering with a company like HANA HealthCare to manage your medical billing and authorization is essential for achieving higher reimbursement.

Process for Seeking Approval for Medical Services in HANA HealthCare: The most effective methods for seeking approval include making a phone call, using the web portal, or sending a fax, depending on the specific rules of the insurance company's plan. It's crucial to ensure you fulfill all the necessary criteria before submitting your request online or by fax. HANA HealthCare employs a team of skilled professionals in the Prior Authorization department who are well-versed in the unique aspects of each insurance company to optimize outcomes and ensure claims are processed promptly with the highest possible reimbursement. We adhere to a consistent checklist that includes the required information and documents based on the insurance company and policy. Below are the essential details that are typically needed by most insurance companies to submit a request for approval:

• Basic personal information of the patient, such as name, birthdate, address, and insurance ID number.
• Information about the provider, including NPI number, Tax ID number, contact phone and fax numbers, and address.
• Details about the facility where the services will be provided, whether it's an office, inpatient, or outpatient setting.
• CPT, HCPCS, and ICD-10 codes along with their descriptions.
• The expected duration of stay for inpatient requests.
• The insurance company might request additional information regarding the patient's medical history and the nature of the service.
• It's mandatory to include the primary reason for the patient's visit, and the insurance company may also request clinical records for further explanation.

Requirements for Approval: The specific requirements for approval may differ based on the guidelines of the insurance plan and the type of service. In general, treatments that are risky or costly typically need approval from the insurance company, as these treatments are aimed at cost-effectiveness, and any errors could lead to financial losses.

• A referral from a Primary Care Physician (PCP) is usually necessary for Health Maintenance Organization (HMO) plans before submitting a request for approval. Not having a referral could result in the denial of the request.
• Most insurance companies require prior approval for imaging services such as MRI, MRA, CT, CTA, PET scans, etc.
• A few insurance companies employ health consultants like Evicore, NIA, AIM specialty, American Health Group, etc., to manage authorization requests on their behalf.
• Emergency services provided on an outpatient basis do not typically require prior approval.

HANA HealthCare adheres to a streamlined approach to ensure a smooth and efficient process for obtaining prior approval, which ultimately aids in the faster processing of claims and an increase in cash flow.