Hospitals to obtain preauthorization when SelectCare’s own member presents with incorrect insurance information. Indeed, this is precisely the type of situation that the exception in Section 2.6 was intended to address.
B. Claims where SelectCare wrongly recouped its prior payment of the claims.
In three instances, SelectCare originally approved and paid the hospitals’ claims, only to later reverse its decision and recoup the payment on a later date.
The first claim is patient M.G., who was admitted to Bayshore Medical Center starting on April 23, 2014. The hospital’s records show that on April 23, 2014, SelectCare representative Jan G issued authorization no. 141050516 and approved the 2 day admission at issue. On April 28, SelectCare representative Mollie A again confirmed this authorization to the hospital. Thereafter SelectCare paid the claim in accordance with the Agreement. However, in September 2014, SelectCare notified the hospital that it was going to recoup its payment because the “authorization has either been denied or voided.” On October 2, 2014, SelectCare representative Jackie informed the hospital that SelectCare’s system showed that the authorization was valid and approved. Jackie further informed the hospital that she confirmed with SelectCare that the authorization was valid, and therefore, was sending the claim to be reprocessed with the valid authorization. Nevertheless, on or…show more content… In both cases, the level of care that had been authorized was provided by the hospitals and was supported by the medical records. Accordingly, the hospitals timely and appropriately appealed SelecCare’s incorrect recoupment of the claims. The hospitals demand that SelectCare pay for the medically necessary services that it authorized and that were provided to its
