Things You Should Know This Week
UHC Denial Patterns Continue
UnitedHealthcare (UHC) continues to deny claims incorrectly, particularly related to authorization requirements and contract status mismatches. These denials often stem from system errors or misclassification of provider participation status, which can lead to payment delays or unwarranted denials.
Action Recommended:
Continue to monitor and audit UHC denials closely to confirm their accuracy.
If you notice recurring denial patterns that don’t align with your contract or authorization records, reach out to us, we’re happy to assist with review and appeals.
CMS Final Rule on Prior Authorizations
CMS has finalized a rule aimed at improving the prior authorization process, which includes:
Implementing electronic prior authorization (ePA) systems to streamline requests.
Requiring payers to provide faster turnaround times for prior authorization decisions.
Enhancing transparency by mandating that payers provide specific reasons for denials.
These changes are designed to reduce administrative burdens and improve patient access to necessary care. View the fact sheet here.
TRICARE West Region Waiver Extended Through June 30, 2025
The Defense Health Agency has extended the temporary waiver of outpatient referral requirements for TRICARE Prime beneficiaries in the West Region through June 30, 2025. This waiver allows TRICARE Prime enrollees to receive outpatient specialty care without prior authorization from TriWest Healthcare Alliance, provided they have a referral from their Primary Care Manager (PCM).
Key Points:
Effective Dates: Referrals issued between January 1 and June 30, 2025, are valid for services rendered through September 30, 2025.
Provider Requirements: Services must be rendered by TRICARE-authorized providers.
This extension aims to ensure uninterrupted access to necessary outpatient specialty care for TRICARE Prime enrollees in the West Region.
BCBS Federal Audit Refund Requests
Many providers are reporting that Blue Cross Blue Shield Federal Employee Program (FEP) plans have initiated refund requests tied to a recent claims audit. These refund letters are being issued for claims dating back several years and appear to be related to coding or documentation discrepancies flagged during the audit.
Key Points:
Refund amounts vary but may span multiple dates of service and patients.
Some letters provide minimal detail, making it important to request full audit findings before issuing payment.
Not all impacted providers were aware an audit had occurred prior to receiving refund demands.
Aetna Denials for Medical Records Increasing
Aetna has resumed denying claims even after medical records have been submitted, including those uploaded directly through Availity, which was previously an accepted method for resolving such denials.
What’s changed:
These claims are now being denied again despite documentation.
Practices are being required to submit a next-level appeal to contest the denial which is adding unnecessary administrative burden and delays in payment.
If your practice is seeing a rise in these denials or needs support preparing appeals, please reach out. We’re actively tracking this issue and can assist in streamlining your response process.