Question
What is the name of your state? New York
For the external appeal, I lost my pre-cert with my HMO. When I had surgery my HMO payed for 4 out of 5 cpt codes and I payed for one. My surgeon said that my frontal bones were thickened, which indicates the medical necessity of the cpt code. Has anyone sucessfully filed a post-cert with their HMO? I would love to hear any pointers that you can give me.
Many thank in advance.
Answer
The HMO's around here are pretty clear that they will not honor retro-active referrals, nor will they pre-cert a procedure retro-actively. The only one we can remember is a case that the procedure was done on an emergent basis and was initially denied for not having a pre-cert. They eventually got it through by submitting paperwork to prove it was an emergency, therefore there wasn't time to pre-cert beforehand. Sorry.
Maybe moburkes or ecmst12 have other information that may be a little more positive for you.
Answer
Are you saying you just lost the form? Your insurance company will have records of their certification. When the procedure needs to be changed mid-surgery because of what they find inside, then the doctor will usually have to submit medical documentation supporting the need for the more advanced procedure. Did he do this?