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Prior Authorizations Under medical and prescription drug plans, some treatments and medications may need approval from your health insurance carrier before you receive care. Prior authorization is usually required if you need a complex treatment or prescription. Coverage will not happen without it.
What is a prior authorization and how does it work?
Prior authorizationsometimes called precertification or prior approvalis a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.
How to do pre authorization?
If your healthcare provider is in-network, they will typically handle all of the paperwork for obtaining precertification or preauthorization. If the provider is out-of-network, they may or may not handle the paperwork for you. It may be up to you to send the forms to the insurance company.
What is an example of prior authorization?
Examples of services that commonly require prior authorization before being approved include: Diagnostic imaging (such as MRIs, CTs, and PET scans) Durable medical equipment (such as wheelchairs) Rehabilitation (like physical or occupational therapy)
How do you initiate prior authorization?
The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patients insurance provider. As mentioned in the How does prior authorization work? section above, this will then often prompt a time-consuming back and forth between the provider and payer.
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