Claim denied because there was no prior authorization (PA)

General
1

As the title says, our insurance denied a claim because no prior authorization ¶ was obtained. Here’s what happened: On July 5th, my husband got a call from his doctor, who had run some labs a few days before. The doctor made an emergency referral to hematology, and on 07/08, my husband was scheduled for an appointment on 07/11. The day before the appointment, the nurses called to let him know he was scheduled for a bone marrow biopsy during the visit. Apparently, our insurance (UMR) requires a PA for this procedure. All other claims related to this appointment, and others, have been approved. The facility and doctors are in-network, and we had already met our out-of-pocket maximum before all of this. Now we’re left with a $6,023 bill. Since we had already met our out-of-pocket max, and my husband was diagnosed with cancer from that biopsy, I’m wondering how to proceed with insurance.

Edit: I spoke with my insurance, and they will accept a retro PA but with a 50% reduction in coverage, up to $500. Based on the comments, it sounds like this is on the physician’s office for not handling the PA, so I’m going to let them deal with that loss.

2

This is mainly an issue for the doctor who ordered the test that needed the PA. The quickest solution is to contact them or their office and ask if they’ll get a retro PA for the test and refile the claim. This is a common process, and securing PAs is the responsibility of the in-network care provider.

3

Oh, I’m very grateful @StephieStephie . Knowing this is beneficial. Usually, I take care of everything when it comes to insurance, but things happened so fast that when I learnt the first details about the cancer, my head was practically fried.