Authorization required list for Healthcare services

Following are list of services that required Authorization, again it will differ from insurance to insurance, below are the most common list. So please refer your insurance documentation for particular requirement.

Inpatient and Observation Admissions, as noted above
Admission to any rehabilitation and skilled nursing facility
All surgical procedures, inpatient or outpatient
The following have special reporting requirements (refer to Forms Section):
Abortions
Hysterectomies
Sterilization procedures
Cosmetic or Reconstructive Surgery, including but not limited to:
Breast reconstruction or reduction
Blepharoplasty
Venous procedures
Sclerotherapy
Services and items:
Allergy (immunotherapy), exept for those services identified on the QAF
Ambulance transportation (non emergent)
Amniocentesis
Cardiac and pulmonary rehabilitation programs
Circumcisions after 12 weeks of age
Court-ordered services
Chemotherapy
Dialysis
DME, including apnea monitors and bili-blankets
Upper endoscopies at colonoscopies at hospitals
Genetic testing
Gamma Knife, Cyberknife
Hearing aids
Home Health Services
Hospice care
Hyperbaric Oxygen Therapy (HBO)
Investigational and experimental procedures and treatments
IV Infusions
Laboratory services in POS 22 and 24
Lithotripsy
Mental Health (See Mental Health Section)
Nutritional counseling
MRI’s, MRA’s
Oral Surgery
Oxygen therapy and equipment
Out-of-Network Services
Pain Management and or Pain Injections
PET Scans
Prenatal care
Orthotics and Prosthetics, including Cranial Orthotics
Physical, Occupational and Speech Therapy
Radiation therapy
SPECT scans
Transplants and pre and post transplant evaluations
Wound Care and wound vacuums
Drugs that require pre-authorization
Any services or procedures not listed on the Quick Authorization Form (QAF)

Comments

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 ...

Key Performance Indicators (KPIs) for Successful Revenue Cycle Management (RCM) in Healthcare Organizations

Revenue Cycle Management (RCM) is an essential process for healthcare organizations to ensure that they receive timely and accurate payments for the services they provide. Here are some of the key performance indicators (KPIs) metrics that healthcare organizations should track as part of their RCM process: Gross Collection Rate (GCR): This metric measures the percentage of charges that a healthcare organization collects from patients and insurance companies. It is calculated by dividing the total payments received by the total charges billed. Net Collection Rate (NCR): The NCR measures the percentage of expected payments received by the healthcare organization after accounting for contractual adjustments, bad debts, and other adjustments. It is calculated by dividing the total payments received by the total expected payments. Days in Accounts Receivable (DAR): This metric measures the average number of days it takes fo...

What is W-9 form? Why it is required for Medical Billing.

W-9 Form W-9 is Internal Revenue Services (IRS) request for Tax Payers identification number, mainly its used for third parties to collect ID information like Name, Address to help file information returns with IRS. Also its is used to help payee avoid backup withholding. It is required for your name, Address and SSN number or employer identification number. When your giving out W-9 form be caution, because W-9 form contains sensitive information’s. Why Insurance Company ask W-9 Form from hospital or clinic etc., Because medical billing is cycle indirectly or directly insurance company’s are working for hospital or clinic etc., for them we need to report SSN number / business tax id. As far as W-9 is form is concern it is straight forward with the all the above mentioned information, also they need to pay to address, or to update their records, or to check / update records. Note: W-4 Form is used by employer ...

Medical Billing

Search This Blog