Pre-Authorizations


(Ellen) #1

Hi,
I’m new here, but I was hoping to get some help. My daughter is type 1 (diagnosed 4 years ago). We live in a rural part of Montana where we need to travel for care. The closest Endo. is about 2 hours away in Idaho Falls, if we stay in state the closest one is 5 hours away. In late 2017 we switched to the Idaho Endo. which worked out nicely for ease of travel. We had insurance through my husband’s job, since then, beginning of 2018 it became too expensive to keep that insurance so we were able to get my daughter on our state Medicaid insurance. When we made the switch I let our doctor in Idaho know and gave them the updated insurance information and asked if there was anything else we needed to do. They said no, we can bill your MT Medicaid insurance. Since then her claims have been denied due to our Endo being an out of state provider. After many, many calls to the Medicaid insurance office, I finally found out today that there is no pre-authorization in place for our Endo. So we are responsible for the entire bill. When I asked how we initiate the pre-authorization, they told me that our Endo’s office has to contact them. When I told that to my Endo’s office, they told me that pre-auths are usually done in the beginning when insurance changes take place. I am so confused, frustrated and overwhelmed. Is there anything that I can do? Is there any help that anybody can offer?


(joe) #2

@MTFamily hi Ellen,

I am sorry I don’t have much to add but I wanted to bump this to the top of the feed in case someone here does.

I have had plenty of fights with my insurance company including a pre-authorization snafu many years ago. In that case, it was because a primary care physician was needed to OK “x-number” of visits to the “specialist”/ I think your situation is more complicated.

good luck hopefully someone can comment.


(Kristi) #3

It’s tough to get out of state providers who accept your state’s Medicaid. But if the Medicaid office is stating that they will provide coverage if pre-auth is obtained, then the doctor should absolutely contact them. Even if it is not what is typically done in their experience, it’s what the insurance is stating needs to be done. Don’t be afraid to push the doctor’s office and request they do this for you! It’s part of their job.


(wadawabbit) #4

When I started with Medicaid in my area this year I was informed that I would need a primary care physician. I found one in their directory and either they or the specialist told me I would need a referral to see specialists (I believe each referral allowed a certain number of visits over a certain time period so be sure to check). The PCP wrote ones for the specialists I found in the provider directory.
In my area there are a couple of different Medicaid plans, and I found out the hard way that just because someone participates in Medicaid that does not necessarily mean the physician is in your particular plan - so be sure to specify which one you have when you book an appointment.
To be honest I’ve found that doctors don’t usually like to back date referrals and specialists usually want them at the time of the visit but it couldn’t hurt to check. Wishing you the best and so sorry to hear about your issues.


(Arnette) #5

I’ve also had problems with ore-authorizations with Medicaid in Nevada. It is frustrating. What I had to do was do a conference call with Medicaid and the doctors office together and pretty much told them to work it out NOW. And they did. Every time my granddaughters prescription changed, it had to have pre-authorization In our situation, the doctors office wasn’t handling their business. It would literally take up to 15 days to get a prescription filled. Don’t give up!!! I just asked them a simple question “which one of you should I sue if something happens to my granddaughter because of your negligence or lack of communication”. I got her prescription in 2 days. Don’t give up!!!