{"id":3557,"date":"2025-06-05T14:26:45","date_gmt":"2025-06-05T14:26:45","guid":{"rendered":"https:\/\/zenmedinc.com\/blog\/?p=3557"},"modified":"2025-06-05T17:32:59","modified_gmt":"2025-06-05T17:32:59","slug":"prior-authorization-denials-in-healthcare","status":"publish","type":"post","link":"https:\/\/zenmedinc.com\/blog\/prior-authorization-denials-in-healthcare\/","title":{"rendered":"Struggling with prior authorization denials? Check these quick improvement tips!"},"content":{"rendered":"\t\t
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Tired of the denial merry-go-round with payers? Is your staff tearing their hair out, along with you? In today\u2019s healthcare landscape, receiving a denied claim can be tricky business if you don\u2019t understand how to appeal a claim. To appeal a denied claim, one must first understand the type of denial you have received, administrative or clinical. Each presents its challenges in the appeal pipeline but can be overcome. Due diligence with back-office staff is paramount to achieving a good ROI on appealing denied claims.<\/span><\/span><\/p>\n

An administrative denial will typically arise from errors in documentation, such as an incorrect identification number on the claim or other technical mistakes. Generally, one can correct the administrative denial via a phone call. <\/span><\/span>If the claim includes an error related to information or a number that was entered incorrectly, it can be corrected and reprocessed without requiring a formal appeal.<\/span><\/span><\/p>\n

A clinical denial typically occurs when insurance companies question the medical necessity of a procedure or treatment or classify the procedure as investigational or experimental. Another common reason for a clinical denial is the absence of prior authorization. Many insurance companies require prior authorization for certain treatments, and providers, as well as staff, may not be aware of this requirement or understand how to request one. If a claim has already been submitted, authorization cannot be submitted or requested retroactively in most cases, however, I always recommend trying, some payers will allow it.<\/span><\/span><\/p>\n

Generally, clinical denials require a lot of steps to complete an appeal within a specified timeframe for consideration. Each state and payer has its own laws\/rules for timely filing of an appeal, and it can be anywhere from 30 to 90 days from the date of the denial. <\/span><\/span><\/p>\n

Denials of prior authorization occur generally due to incomplete information, lack of medical necessity, or coding errors. However, there are other frequent causes, such as administrative errors, and everyone\u2019s favorite, Non-Covered Services. To assist providers and their staff through this maze, The American Medical Association (AMA) is proactively working to help regulate these ongoing issues with prior authorization denials across the healthcare landscape.<\/span><\/span><\/p>\n

Let\u2019s take a more detailed look at the ongoing challenges facing providers and staff:<\/span><\/span><\/p>\n