04/18/2023
Health Alliance Plan
Health Alliance Plan Managed Care Committee Member
April Danish, CHONC - Newland Medical Associates
Managing Prior Authorizations
We listen to your feedback and want to ease the administrative burden for our provider partners. In 2022, we removed the prior authorization requirement on approximately 20% of codes. We review national and local trends to ensure we are aligned with industry standards. We will continue to evaluate prior authorization requirements for further reductions.
Save Time!
If an authorization isn’t required, don’t submit it. Check our prior authorization list first!
• Log in at hap.org
• Select Quick Links, Procedure Reference Lists, then Services that Require Prior Authorization List
• Search by code and refer to the Prior Auth Required column
Online authorizations application
If an authorization is required, submit it online. It’s the most efficient method. There are help guides available with step-by-step instructions and illustrations. You can find the guides, including a quick reference guide, when you log in at hap.org; select Quick Links then Authorizations-CareAffiliate Help.
If you need more help with the online authorizations application, email providernetwork@hap.org and put “CareAffiliate help” in the subject line.
Denials – When To Submit a Corrected Claim vs. an Appeal
Corrected claim submission
If we deny a service for missing or incorrect information, and you agree with our decision and want to submit a corrected claim, then:
- Follow our Process for Submitting Claims Corrections. It can be found online. Log in at hap.org, select Quick Links, then Billing Manual.
Important! Providers have one (1) year from the date of service to submit a corrected claim.
Denials include, but are not limited to:
- Incorrect date of service
- Incorrect diagnosis or ICD-10 Manual guidelines not followed
- Missing NDC
- Inaccurate CPT/HCPCS/REV code
- Missing modifiers or incorrect modifiers (with the exception of the modifiers listed below), such as anatomical, DME, therapies,
- Over billed units
Appeals
If you disagree with the denial and submitting a corrected claim will not resolve the issue, then:
- Submit an appeal letter and medical records within 60 days of the original denial date
- Do not keep submitting corrected claims to resolve a denial issue
- The denial must be resolved on the original claim.
You can find the appeals process online. Log in at hap.org, select Quick Links, then Billing Manual.
Denials include, but are not limited to:
- Mutually exclusive procedures
- Units billed appropriately
- Exceeds clinical guidelines
- Included in the global surgical package
- Modifier missing – see list of modifiers below
Missing Modifiers Requiring Appeal and Corrected Claim
If we deny a service for an unsupported modifier or you determine modifiers 24, 25, 27, 57, 59, 76, 91, XE, XS, XP, or XU should have been billed, then:
- Submit an appeal with medical records and a hard copy corrected claim.
- Do not just add a modifier on the claim that would bypass the edit/denial. This may cause the service to be denied again.
Important!
- Modifiers XE, XS, XP, and XU give greater reporting specificity in situations where you used modifier 59 previously. Use these modifiers instead of modifier 59 whenever possible.
- Only use modifier 59 if no other, more specific, modifier is appropriate.
- All modifiers must be supported in the medical records.