Prior Authorization Appeals
For additional prior authorization information regarding a specific BMS product, please click on the Products page.
Some health insurers require that a prior authorization be issued before certain items or services are covered. Failure to obtain a prior authorization from some health insurers before service is rendered (“prior authorization”) may cause a claim to be denied coverage, despite the fact that the claim would have otherwise been covered. A prior authorization is typically required only for items and services that are named by the health insurer.
Physicians and patients can appeal an insurer's decision to deny a prior authorization. Many states mandate that insurers maintain coverage appeal processes, including an expedited process that must be completed within a relatively short period of time (eg, 72 hours). Preparation for the appeal of a denied prior authorization is much the same as preparation for the appeal of claims that are denied coverage, as discussed below.
Some insurers will make a predetermination of coverage decision upon request. A predetermination generally applies to an item or service for which the health insurer does not require a prior authorization. If, after providing a predetermination decision, the health insurer indicates that the item or service will be denied coverage, the physician or patient can appeal the decision.