Identify and explain the process of the MCP with regard to Check Referrals, Preauthorizations, or Second Opinions

Question

What will be an ideal response?

Answer 1

Answer:
Those items that are the financial responsibility of the MCP should have had referrals or preauthorizations performed. In some cases a second opinion may also have been required. Check to be sure that all the proper paperwork was done.
If the paperwork was not done, check the contract to determine what the impact will be on the coverage of those services.
The preauthorization will often be accessible by computer, so the claims examiner should be able to check it quickly and easily. Often a preauthorization number will be included on the claim. If a preauthorization number is not included, you must check the system for the preauthorization. Not having a preauthorization number on the claim is often not considered a valid reason for denying payment on a service since the claims examiner has access to that information.
If the referrals, preauthorizations, or second opinions were done, process the claim. If the referrals were not done, deny or reduce benefits accordingly and process the claim.