Selectcare Varying Claim Analysis

The highlighted language is a broad and material exception to the operation of Section 2.6. SelectCare is prohibited from denying a medically necessary claim under circumstances where good cause existed for the lack of prior authorization. This exception prevents SelectCare from unreasonably shifting the costs of its member’s medically necessary services to the Hospitals when the Hospital is not at fault. As discussed more fully below, good cause existed for the lack of authorization on each of the claims at issue. Accordingly, SelectCare’s denial of these medically necessary claims was unreasonable and payment should be made to the Hospitals.

A. Claims where the SelectCare members presented to the Hospitals with incorrect insurance information.

Several of the claims involve circumstances where good cause existed for the lack of authorization because the SelectCare member presented to the Hospitals with incorrect insurance information. The fact pattern in each of these claims is similar: the member presented incorrect insurance information to the hospital, the insurance information presented was verified by the hospital …show more content…
At the time of registration, the member/patient presented the hospital with a Medicare Part A & B insurance card. The hospital verified this insurance through the Passport system and then submitted its initial a claim to Medicare on June 11, 2014. The claim was rejected, and then the hospital learned that the patient was insured through SelectCare. Accordingly, the hospital promptly submitted a claim to SelectCare, but it rejected the claim due to a purported lack of authorization. SelectCare maintained its denial through two-levels of appeal by the hospital based on SelectCare’s position that the hospital should have checked the Medicare Common Working File to verify the patient’s insurance