Prior Authorization and Denial Management


Prior Authorization and Denial Management

Most elective procedures require a process which allows providers to determine coverage and secure an approval from a payor for a proposed treatment or service. However, not all procedures are approved, mainly due to missing information. Physicians and patients have the right to appeal a denial, which consists of both internal and external reviews. This section includes templates for use by providers when seeking prior authorization or appealing denials.

The resources below provide suggested instructions and a summary of guidelines for facilitating prior authorization or appeal requirements. They are not an endorsed resource of any insurance company, and providers are highly encouraged to review each payer policy and requirements for prior authorization and medical guidelines.

  • This is a sample letter template that provides suggestions for writing a Letter of Medical Necessity or prior authorization request for Atrial Fibrillation. Clinicians should customize the letter based on the patient's medical history, diagnosis, and any specific prior authorization requirements from the health plan.

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Health Economics & Reimbursement Disclaimer

This material and the information contained herein is for general information purposes only and is not intended, and does not constitute, legal, reimbursement, business, clinical, or other advice. Furthermore, it is not intended to and does not constitute a representation or guarantee of reimbursement, payment, or charge, or that reimbursement or other payment will be received. It is not intended to increase or maximize payment by any payer. Abbott makes no express or implied warranty or guarantee that the list of codes and narratives in this document is complete or error-free. Similarly, nothing in this document should be viewed as instructions for selecting any particular code, and Abbott does not advocate or warrant the appropriateness of the use of any particular code. The ultimate responsibility for coding and obtaining payment/reimbursement remains with the customer. This includes the responsibility for accuracy and veracity of all coding and claims submitted to third-party payers. In addition, the customer should note that laws, regulations, and coverage policies are complex and are updated frequently, and, therefore, the customer should check with its local carriers or intermediaries often and should consult with legal counsel or a financial, coding, or reimbursement specialist for any questions related to coding, billing, reimbursement, or any related issues. This material reproduces information for reference purposes only. It is not provided or authorized for marketing use.

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