Meritain Prior Authorization List (2024)

FAQs

Why do prior authorizations get denied? ›

Prior authorization requests can be denied or delayed because of seemingly mundane mistakes. A simple mistake could be having the request submitted for a patient named John Appleseed when the health plan member's health insurance card lists the member's name as Jonathan Q.

If you don't obtain it, the treatment or medication might not be covered, or you may need to pay more out of pocket. Review your plan documents or call the number on your health plan ID card for more information about the treatments, services, and supplies that require prior authorization under your specific plan.

These steps are usually done manually, often through a cascade of phone calls, faxes and emails between payer and provider. The responsibility falls on the provider to continue to follow up with the insurance company until there is resolution of the prior authorization request — an approval, redirection, or denial.

Submit an appeal.

This is a written notice challenging a denial or requesting an exception to the plan's policies. Even out-of-network providers can appeal, or if it was your error that led to the denial. Contact the plan for details about its appeal process and filing deadlines.

If a guest has insufficient funds for the pre-authorization itself, then the transaction should be declined outright.

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.

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

Your medical provider will generally take the lead on submitting a prior authorization request and communicating with the health plan to improve the odds of approval. But the more you know about this process, the better you can advocate for the care you need.

What is the proper response to a failure to obtain pre-authorization denial? ›

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.

Prior authorization—sometimes called preauthorization or precertification—is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.

Taking into consideration the complexity of a prior authorization request, the prior authorization process selected by a healthcare provider, requirements set out in individual health plans, and any subsequent appeals process, a prior authorization (PA) can take anywhere from same day to over a month to process.

Minimize Authorization Denials with These Top Tips

Here are some key strategies: Before Submitting: Verify Patient Eligibility: Double-check that the patient's insurance is active and covers the requested service. Confirm Need for Authorization: Not all services require prior authorization.

Insurance companies will deny claims if it determines that coverage has lapsed. There are a few different reasons why insurance coverage may lapse: failure to pay premiums on time, insurer unilaterally canceled the policy, or the insurance company no longer exists.

This will most often result in a “soft” denial remedied by resubmitting forms in accordance with the payer's updated specifications.