The provider said no prior authorization was required, but the claim was denied. What now?
You need to determine whether the plan truly required authorization, whether the provider checked the wrong payer or code, or whether the denial is actually for medical necessity after the service. Get the provider's verification record, the plan rule, and the billed codes, then ask for reprocessing or file a member appeal while the provider corrects its side.
What to do, in order
- Step 1
Get the verification details
Ask the provider for the date, reference number, payer contacted, codes checked, and what the plan said.
- Step 2
Compare codes and benefit
A no-auth answer for one CPT, diagnosis, facility, or benefit does not always apply to the code actually billed.
- Step 3
Ask the plan for the auth rule
Request the rule showing prior authorization was required on the date of service for that code and provider setting.
- Step 4
Protect your member appeal
Even if the provider should fix it, file the member appeal before your deadline and ask the provider to hold billing.
The deadline that applies
Use the appeal date on the EOB or denial notice, generally at least 180 days on employer and ACA plans. Provider reconsideration or contract windows may be shorter.
Calculate your date →Documents to gather
- EOB or denial
- Provider verification record
- Billed codes and itemized claim
- Plan prior-authorization rule
- Provider billing hold request
Go deeper
Related questions
Does a no-auth-required call guarantee payment?
No, but the reference number is evidence. It can support reprocessing if the plan gave wrong information.
Who is responsible if the provider checked the wrong code?
Often the provider has to correct or appeal its billing, but you should still protect your member appeal rights.
Can I demand the provider write off the bill?
Ask for a hold and dispute in writing. Whether a write-off is required depends on network contract, state law, and the facts.
Sources
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