The clinicals can be perfect. If the rendering provider is out of network, the HMO answer is still no.
Key Takeaways
- On HMO and EPO plans, network status can decide a request before anyone reads the clinicals.
- Verify the rendering provider’s network status before submission, every time.
- Urgent cases with no in-network option need two things documented: the urgency and the lack of an in-network provider.
The case
A 44-year-old Healthfirst HMO member was referred to a pain management specialist for a nerve block. The specialist was not in the Healthfirst network.
The referring office prepared the prior authorization and listed the out-of-network specialist as the rendering provider.
Why this request was at risk
HMO plans generally cover care only from in-network providers, apart from emergencies and approved exceptions. A prior authorization is tied to the provider who will perform the service, so listing an out-of-network rendering provider puts the request on a direct path to denial, no matter how strong the clinical documentation is.
In our team’s experience, Healthfirst enforces network rules closely.
What our team checked
- Is the rendering provider in network with the patient’s plan?
- Is there an in-network specialist who can perform the service?
- Is the care urgent or emergent, with no in-network provider available?
What we did
Our specialist caught the network problem before the request went out and escalated it with the practice. The options were to redirect the referral to an in-network pain specialist, or, if the case was urgent and no in-network provider was available, build the request around documentation of both facts.
If no in-network path can be identified, the right step is to pause and escalate, not to submit and wait for the denial.
The documents that close the gap
Where our team sees this most often
Healthfirst and most HMO and EPO plans.
A question for your team
Who on your team checks the rendering provider’s network status before the PA goes out?
Want a prior authorization team that reads the chart and the plan before every submission? Talk with DataMatrix Medical.
More from this series: see all six prior authorization case studies.
This case is drawn from a real prior authorization request our team handled. We removed identifying details to protect patient privacy. Payer policies change and vary by plan, so the same steps will not produce the same result in every case. This article is educational and is not legal, billing, or clinical advice.
Nathaniel Smathers is the VP of Client Education and Marketing. He is also a long time contributor of the DataMatrix Medical blog and has a background in healthcare content creation for over a decade. Nathaniel is passionate about exploring the intersections of healthcare, data analysis, and digital innovation.
