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The intent of prior authorizations is to ensure that drug therapy is medically necessary, clinically appropriate, and aligns with evidence-based guidelines.
What triggers a prior authorization?
The prior authorization process begins when a service prescribed by a patients physician is not covered by their health insurance plan. Communication between the physicians office and the insurance company is necessary to handle the prior authorization.
What is the reason for prior authorization?
The prior authorization process can help you: Reduce the cost of expensive treatments and prescriptions by first requiring you to try a lower-cost alternative. Avoid potentially dangerous medication combinations. Avoid prescribed treatments and medications you may not need or those that could be addictive.
Why would insurance deny a prior authorization?
If the proposed treatment doesnt meet the threshold for being medically necessary, it wont be reimbursed by the payer. If a providers office submits a wrong billing code, misspells a name or makes another clerical error, this can result in a denied PA request.
What does a prior authorization literally mean?
A prior authorization literally means: before the insurance pays for the medication, authorization must be obtained.
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FAQ-Prior Authorization | Department of Human Services
Prior authorization sometimes called preauthorization or precertification is a health plan cost-control process by providers must obtain advance approval.
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