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Medical Pre-authorization

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Payment implications for failure to timely notify or pre-authorize services

Effective with admission dates of service on or after July 1, 2013, failure to provide notification of inpatient admission or secure approval for services subject to pre-authorization will result in claim non-payment and provider liability. Our members must be held harmless and cannot be balance billed.

Please note the following:

  • If the facility follows the inpatient admission and discharge notification requirement indicated above, they will not be subject to any pre-authorization penalties for failure by the physician or other health care professional to pre-authorize a service. We will review for medical necessity.
  • If the physician or other health care professional follows the pre-authorization requirements outlined on our pre-authorization lists, they will not be subject to any penalties for failure of the facility to provide the required inpatient admission and discharge notification. We will review for medical necessity.
  • The following are facility pre-authorization requirements prior to patient admission:
    • Inpatient rehabilitation
    • Skilled nursing facility (SNF) care
    • Long term acute care facility (LTAC) care
    • Residential treatment for mental health and chemical dependency
  • An inpatient admission and discharge notification or pre-authorization do not guarantee payment for requested services. Regence reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits. Services must always be medically necessary.

Notification Timeframe Reimbursement
There will be four situations where exceptions to not obtaining a pre-authorization or failure to notify us of inpatient admissions may apply as part of our Administration Dispute Exception Criteria include:

  1. Member presented with an incorrect member card or member number.
  2. Natural disaster prevented the provider or facility from securing a pre-authorization or providing hospital admission notification.
  3. Member is unable to communicate (e.g., unconscious) medical insurance coverage. Neither family nor collateral support present are able to provide coverage information.
  4. Compelling evidence the provider or facility attempted to obtain pre-authorization or provide hospital admission notification. The evidence shall support the provider or facility followed our policy.

Note: A copy of the provider's or facility's fax cover sheet indicating the member health plan information and a fax confirmation from the fax machine showing the fax was successfully sent to the appropriate health plan fax number will be considered compelling evidence.

Learn how to appeal an administrative denial.