Authorization Guarantee procedure limits the medical group/IPA’s risk of rendering care or incurring financial risk for services provided to ineligible members where the individual’s lack of eligibility is only determined after services are provided. It offers reimbursement to the medical group/IPA providing covered services to a member who:
Medical group/IPA provides or arranges for health care services for an eligible member through our eligibility determination and verification processes. If authorization is provided, and the individual was not a member when the
health care services were provided, medical group/IPA may seek reimbursement for such services:
The medical group/IPA must follow the Authorization Guarantee billing procedures. Eligible services must be reimbursed within 45 business days of receipt of information. Reimbursement should be at the cost of care rates listed in the contract, no greater than the full uncollected balance. The medical group/IPA must reimburse the care provider.