Hi bguthrie! Great questions!

1)Can I send a claim for the initial exam (completed in order to accurately submit a pre-auth) along with the preauthorization claim for the appliance? I understand they are two separate claim forms, just not sure which one I should send first.
Yes you can!! As long as the patient has benefits to your office (i.e. make sure the patient has out of network benefits on their policy if you are an out-of-network provider with their medical insurer). Most of the time, you will not pre-auth a consultation appointment, so, once the appointment is done, go ahead and file the claim! During the consultation appointment you will be able to gather the details you will need from the patient to submit the pre-authorization - like diagnosis, sleep study, health history, epwoth score, cpap trials, etc. So, as soon as that appointment is done, you can go ahead and create the pre-authorization letter/claim for the appliance and get it sent off! Doesn't really matter which one does first, but the pre-auth will probably be your main priority :) (most insurers allow you to send claims for services anywhere from 30 day to 12 months after they happen!)


2)Do I send the SOAP report just with the pre-auth for the appliance? Does any supporting evidence need to go with the exam claim?
You definitely want to send the SOAP report (narrative report addressed to insurer) for the pre-authorization! As for the claim for the initial consult - it's up to you. If it is your first few claims with a new medical insurer, they will probably ask to see it! After a while, you may not need to send a report for your office visits codes (E&M codes - 99201-99205, 99241-99245, 99211-99215).


3) When verifying benefits, I was unable to actually speak with anyone, they just faxed benefit information to me. Can I attach a letter asking for a gap waiver/exception with the pre-authorization?
Yes you can! I have personally found it more effective to submit the pre-authorization request and GAP request separately (at the same time is fine, just separately :) - because many times i have found they will go ahead and process the pre-auth and authorize at an out-of-network level, and completely ignore my GAP request and i have to resubmit! Many times your pre-auth will go to the pre-auth department, and your GAP will go to "utilization management" or "medical review" or "provider center".

Hope this helps, let us know if you have any further questions!