Skip to main content

Medicare pre-authorization

Recently, Novitas Solutions has received numerous requests to provide pre-authorization for surgery scheduled to occur within days. Traditional Medicare does not provide pre-certification or pre-authorization of a surgery. Medically necessary services should not be withheld or delayed.

Medically necessary services that have been provided to the patient are billed to Medicare for consideration and processing. If a service is denied, the provider and the patient have a right to request a redetermination of the denial.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) allows coverage and payment for items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.

Section 1862(a)(1)(A) of the Social Security Act is the basis for denying payment for types of care, specific items, services, or procedures, not excluded by any other statutory clause, meet all technical requirements for coverage, but are determined to be any of the following:

Not generally accepted in the medical community as safe and effective in the setting and for the condition for which it is used;
Not proven to be safe and effective based on peer review or scientific literature;
Experimental;
Not medically necessary in the particular case;
Furnished at a level, duration or frequency that is not medically appropriate;
Not furnished in accordance with accepted standards of medical practice; or
Not furnished in a setting (such as inpatient care at a hospital or SNF, outpatient care through a hospital or physician's office or home care) appropriate to the patient's medical needs and condition.
To be considered medically necessary, items and services must have been established as safe and effective. That is, the items and services must be:

Consistent with the symptoms or diagnosis of the illness or injury under treatment;
Necessary and consistent with generally accepted professional medical standards (e.g., not experimental or investigational);
Not furnished primarily for the convenience of the patient, the attending physician or other physician or supplier; and
Furnished at the most appropriate level that can be provided safely and effectively to the patient.

Comments

Popular posts from this blog

What is QMB / MQMB stands for?

In Medical billing or Healthcare industry The term QMB stands for Qualified Medicare Beneficiary & MQMB stands for Medicare Qualified Medicare Beneficiary. The term "QMB" or "MQMB" on the form indicates the client is a Qualified Medicare  Beneficiary (QMB) or a Medicaid Qualified Medicare Beneficiary (MQMB). The Medicare Catastrophic Coverage Act of 1988 requires Medicare premiums, deductibles, and coinsurance payments to be paid for individuals who meet the following criteria:  Important: Clients limited to QMB are not eligible for THSteps or THSteps-CCP Medicaid benefits.  Note: Clients eligible for STAR+PLUS who have Medicare and Medicaid are MQMBs. Medicaid reimburses for the coinsurance and deductibles as well as Medicaid-only services for the MQMB client. QMBs do not receive Medicaid benefits other than Medicare deductible and coinsurance liabilities. MQMBs do qualify for Medicaid benefits not covered by Medicare in addition

Rejection Procedure note qualifier is missing

  Need to check the Charges tab and double click on the Procedure Code line to open up the Charge Entry window. There is a Notes section on the right hand side. If there is a note typed, we need to select the type.   Need to select field and select the appropriate type of note you are sending.   Save the changes made   Check all the procedure if submitted many procedure.   Save the visit again and submit the claim.

Mastering the 'Tell Me About Yourself' Interview Question: Best Tips and Examples

In a job interview, the "Tell me about yourself" question is often asked early on and is an opportunity to make a positive first impression. The key is to provide a comprehensive response that highlights your qualifications and aligns with the job you're applying for. Here's a structured approach to crafting the best answer: Start with a Brief Personal Introduction: Begin by mentioning your name and your current or most recent role, if applicable. For example, "I'm [Your Name], and I'm currently working as a Sr AR Specialist at XYZ Company." Provide a Summary of Your Professional Background: Offer a concise overview of your professional journey, emphasizing the experiences and skills most relevant to the position you're interviewing for. You can mention your years of experience, notable career achievements, and areas of expertise. Highlight Relevant Achievements: Share specific accomplishmen