1. Prior Authorization means - a product or service must be requested and approved before the product or service is provided.
2. If the provider goes ahead with the product or service before doing a PA (ie: Friday late afternoon, or weekend or just plain forgot) - the provider has 48 hrs. to enter the PA and is at risk for non-payment if the product or service goes to review and is denied. If the product or service meets criteria and the 48 hr. rule it will be approved retro.
3. Providers should always check the grid before proceeding to see if an item needs a PA. If not, they can go ahead without risk unless it is eventually shown that the product or service was done for a below the line condition for OHP members.
4. If the provider sees a member who gives them erroneous insurance information ie: Medicare Prime instead of CCMA or OMAP fee for service instead of COIHS/OHP, and the provider finds out about it within 90 days - they can enter a retro request and services will be reviewed and covered if they meet criteria just like they would have if done in a timely fashion.
If the provider HAS billed and the EOB denial states “No Pre-auth”; the office MUST ask for a Provider Appeal.