Can you guide me to find any sort of legal back up PPO's have to obtain preauth or I'm not liable
I had a procedure done that my Doctor did not preauthorize and my INS co says "Not medically necessary" I was hoping you could guide me to any law that would back up the statements you made about me not being financially responsible if they don't get the authorization. The doctor is in my network of preferred providers.
Please go to my profile page and choose contact me- want some more info- was this emergency room, surgery? Whoever provided the treatment, if they are a member of the PPO, in their contract with the insurance company, they have a clause that says they will get auth or they will not bill you. I have, in the past, asked to see a copy of the md's contract, found the clause and pointed it out to them- but need to know what kind of service...If you were an inpatient at your member hospital, they MUST get auth- they know this- Please check to see if your state has a dept of managed care. If not, you need to file all of the info regarding what happened with the Insurance Commissioner. If there is a Dept of Managed Care, file with them. Then you need to tell the provider who is billing you that you have filed a complaint.
Also, your doctor can ask the ins co for a retroactive auth. They need to submit the records to show that it was medically necessary and help you appeal the ins co decision.
Was it a medically necessary thing? For example, most plastic surgery is not medically necessary, so that would be an exception.
Sorry- I don't have enough info to give you really specific advice, but would love to be able to help you.
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