Can insurers elect not to provide preauthorization at all?
Pursuant to SB 418, a physician or provider can request a preauthorization only where the carrier has determined that certain services require preauthorization. That carrier, having established the requirement, does not have to issue a preauthorization for proposed services. Q: Suppose an HMO requires preauthorization for all hospital stays. An enrollee needing surgery is referred by his doctor or the HMO to a non-contracting specialist because that type of surgeon is not available in-network. The surgeon requests verification of the surgery and the HMO declines. Since SB 418 does not give a non-contracted referral doctor access to the preauthorization process, does he have any recourse to prevent denial of payment due to no preauthorization? A: In this situation, the surgeon has asked for verification but the plan declined, so verification is no longer an option in this instance. He doesn’t have access to the SB 418 preauthorization process. Therefore, the process that remains for the
