Examples Of Prior-Authorization Process For Zimmer Inc.

Prior-authorization Process Procedure
Ryan Arnold Indiana Tech

Prior-authorization can be defined as a requirement through which healthcare insurance companies determine if you are covered a procedure, medical service, or medication. The insurance company might need some personal information such as the name, age, and medical necessities. The process’s main concern is cutting costs, this is especially true when the medication is costly. Without authorization the insurance may deny coverage for the patient. The insurance company has the final say, the doctor does not have this. Below is a sample of Prior-Authorization Process manual for Zimmer Inc. When a patient is supposed to be treated by HCP National Insurance Services,
A well written request form must now be written to the department. Additional information should now be provided to the prior-authorization department which includes: diagnosis code(s), Current Procedural Terminology (*CPT) code(s), description of procedures, and product specific description. Any additional information requested should be provided to the department or utilization review nurses. A bi-weekly follow-up may be performed to check prior-authorization status. The insurance agent contact information should be recorded. Some of the crucial information that must be included are: name, telephone number, extension, fax number. They should also note the time and date of
If it decided to not appeal the process, the process should end there. If it decided to appeal, a letter of denial from either the payer or the patient should be obtained. The letter should contain contact information and well written, precise instructions. The payer must be contacted for clarification of instructions or whether the denial can simply be corrected by providing information over the telephone. If possible, utilization nurses or medical directors should be contacted to discover reasons for denial. Documentation should be provided to the appeals department such as: letter of medical necessity, clinical notes, description of procedure, and product-specific descriptions and clinical information. Status’ will be followed up with the payer 10-15 days and 20-30 days into the process. If a decision is not made within 30 days, follow-ups will continue until a final determination is made. If the appeal is approved, the process shifts to HCP treating the patient as previously noted. The second level is similar to the previous. The difference between the two are: HCP may request peer-to-peer telephone conversations with the payer, and additional documentation to show necessity for