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Under prior authorization, the provider or supplier submits the prior authorization request and receives the decision before services are rendered.
Pre-certification or prior authorization is important for certain procedures or medication due to the following reasons: Pre-certification helps determine if the procedure or treatment is medically necessary and if it is covered by the policy.
This extra step helps both your doctor and the insurer feel comfortable that the medical item is needed and medically necessary for your care. Sometimes they are called pre-approvals, or prior approvals, or prior authorizations, but they all mean the same thing.
The process of preauthorization aims at reducing duplicate services and costs for the payer. An authorization that is not approved interrupts the patient treatment process due to procedures that are not sanctioned, missing patient information, or incomplete medical documentation.
What is prior authorization? This means we need to review some medications before your plan will cover them. We want to know if the medication is medically necessary and appropriate for your situation. If you dont get prior authorization, a medication may cost you more, or we may not cover it.

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The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patients insurance provider.
Pre-certification or prior authorization is important for certain procedures or medication due to the following reasons: Pre-certification helps determine if the procedure or treatment is medically necessary and if it is covered by the policy.
If prior authorization is needed, potential CPT codes that will be billed along with the ICD10 codes of the patients diagnosis must be submitted to the insurance company. The insurance company will then decide whether to allow authorization for the procedure to be billed.

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