Does approving a request for authorization as medically necessary mean the providers bill as submitted must be paid?
A. Not necessarily. The UR regulations require paying ‘appropriate reimbursement’ for the approved treatment. If the bill for treatment is properly documented and correct, based on appropriate codes and on the appropriate fee schedule, it must be timely paid. If the claims administrator disputes part of the bill for whatever reason, the uncontested portion must be timely paid and the claims administrator must comply with the regulations that govern billing disputes.
Related Questions
- What should a provider do if a SAE is discovered several weeks or months after the claim for the admission has been submitted and paid?
- I understand the discount applies to uninsured patients for medically necessary health care services. What exactly does that mean?
- Does approving a request for authorization as medically necessary mean the bill for that treatment will be paid?
