My scan was pre-approved and then the claim was denied. What now?
An authorization is a clinical decision that the service is appropriate; a claim denial after it usually means a mismatch, not a change of mind: a different code, site, date or provider than the one authorized, or an eligibility or network issue. Compare the denial line by line to the authorization letter and ask for reprocessing under it.
What to do, in order
- Step 1
Match the authorization to the claim
Put the authorization letter next to the EOB. Check the procedure code, the facility, the date window, the ordering and rendering provider, and the number of units. One mismatch is usually the whole explanation, and the provider's billing office fixes it with a corrected claim.
- Step 2
Challenge a medical-necessity reversal
Most states bar an insured plan from denying an authorized service on medical-necessity grounds after the fact unless the authorization was obtained on wrong information. Quote the authorization number and date and ask for the provision that permits the reversal. On self-funded plans the plan document governs; ask for the authorization terms.
- Step 3
Ask the imaging centre to hold the bill
In writing, pending reprocessing. Give them the authorization number; they need it for the corrected claim.
- Step 4
Appeal if the insurer refuses to reprocess
Attach the authorization, the EOB, the corrected claim if any, and a letter asking for the specific reason and provision.
The deadline that applies
At least 180 days from the EOB or denial notice on ERISA and ACA plans (29 CFR 2560.503-1; 45 CFR 147.136). The provider's window to file a corrected claim is set by its contract and is often shorter, so ask them to act first. The letter controls.
Calculate your date →Documents to gather
- The authorization letter with number and dates
- The EOB or denial with the reason code
- The itemised claim as billed (codes, provider, facility, date)
- The corrected claim confirmation, if the provider refiled
Go deeper
Related questions
Is an authorization a guarantee of payment?
The letter usually says it is not, because eligibility and benefits still apply. It is strong evidence on medical necessity and on the service matching what was approved.
Who files the corrected claim?
The provider. You file the appeal if the insurer refuses to reprocess.
The authorized code differs from what was done. Now what?
The provider must explain the change and the insurer may review the new code. Ask both in writing.
Sources
Upload the denial letter. A senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.
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