Pending Authorization Q & A
What does it mean when my exam is pending authorization?
There are several reasons why your exam may be pending authorization. First, it should not be assumed that it was denied authorization, only that more time and/or information is needed to complete the process. Oftentimes, your chart notes from your doctor must be obtained and sent to the insurance company for review. The staff at Radiology Regional will ensure that is accomplished so you don’t have to.
I received a text notification canceling my appointment due to an authorization issue, but I called my insurance company and they told me that I am fully covered.
Your exam may be a fully covered service; however, your insurance company requires prior authorization before you can have the exam. The prior authorization comes from a third-party clearinghouse, not your insurance company. A few examples of insurance clearinghouses are NIA, Evicore, CareCore, AIM, etc. Prior authorization /pre-certification can take as little as a few minutes to as long as two weeks. It all depends on the clearinghouse’s requirements for certain exams and adequate documentation of your medical history.
My exam is pending authorization; can I pay with cash or credit card for the exam instead of using my insurance?
No. Due to our contract with your insurance company, we are prohibited from offering a self-pay rate prior to approval or denial of your authorization. Once the exam has been approved or denied, you may opt to be self-pay, and a self-pay rate can be provided to you at that time, upon request.
How will I know that my authorization is no longer pending, and has been approved or denied?
The staff at Radiology Regional will contact you once your authorization has been approved or denied. The insurance company also communicates with your referring provider, Radiology Regional, and you, the patient. Please do not call the office to inquire, as the notification you received is the most current information. If your authorization has been approved, we will contact you to provide you with the next available appointment. If your authorization has been denied, we will inform you of the denial and give you the option to self-pay.
What will happen if my exam is denied authorization by my insurance company?
First, the staff at Radiology Regional exhausts all resources to provide the information needed by your insurance company. If your exam is denied authorization, you will receive a phone call to notify you and offer the self-pay rate for the exam.
Why was my exam denied by my insurance?
Reasons that an exam might be denied include:
- The exam ordered may not be a covered service or meet medical necessity as determined by your insurance plan or the insurance management company (clearinghouse)
- Your insurance company may require a different exam or alternative therapy prior to authorizing your exam
- Length of time since you last had the same exam
- Multiple exams ordered for the same visit or date of service
- A peer-to-peer discussion is required between your doctor and the insurance company
What is a Peer-to-Peer discussion?
A peer-to-peer discussion is a discussion required by your insurance company between your ordering provider and the insurance company. The discussion must be initiated by your order provider within the timeframe allotted by the insurance company. Failure to do so often results in denial of authorization. If your authorization has been denied, we will inform you of the denial and give you the option to self-pay.