My infusion was denied for no prior authorization but the hospital said it was approved. What now?
Get the authorization number the hospital holds and match it to the claim; most of these denials are a mismatch between the authorization and what was billed, or an authorization that was requested and never answered. Then read your certificate: many plans say a missing precertification leads to a retrospective medical-necessity review, not an automatic denial, and the appeal asks for exactly that.
What to do, in order
- Step 1
Get the authorization record
Ask the hospital's authorization or billing office for the reference number, the date, the codes and dates approved, and who at the insurer gave it. If they only have a phone note, ask for the date and the representative's name.
- Step 2
Match it to the claim
Compare the drug code, units, facility, provider and date on the EOB with the authorization. A different site, a different code or a date outside the window is the whole explanation and the provider fixes it with a corrected claim.
- Step 3
If the request was made and never answered
Collect every written request for authorization and every reply. A plan that was asked and did not decide cannot then deny for want of the decision it never issued; put the dates in the appeal and ask for the plan's pre-service decision timeframe.
- Step 4
Ask for the certificate's actual consequence
Quote the precertification section of your certificate. If it says services without precertification are reviewed for medical necessity after the fact, ask for that review in the appeal and attach the clinical records that show the drug was medically necessary and continuing therapy.
The deadline that applies
At least 180 days from the EOB or denial on ERISA and ACA plans (29 CFR 2560.503-1; 45 CFR 147.136). Pre-service authorization requests themselves must be decided within 15 days (72 hours urgent) on ERISA plans; a missed decision is evidence in the appeal. The letter controls.
Calculate your date →Documents to gather
- The EOB with the denial reason
- The hospital's authorization record or the dates of its requests
- Your own written authorization requests and every reply
- The certificate's precertification section
- Clinical records showing continuing therapy and necessity
Go deeper
Related questions
Is a missing authorization always the member's fault?
No. In-network providers usually carry the duty; for out-of-network or care abroad the certificate says who must ask. Read the row that applies to you before you concede anything.
The plan paid the same infusion last time without an authorization. Does that help?
It shows the drug is a covered, continuing therapy. Cite the paid claim number in the appeal.
Can the plan deny a continuing therapy for a paperwork reason?
It can try. The appeal turns a paperwork denial back into the medical-necessity question the certificate actually asks.
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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