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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.
Prior authorization (also called preauthorization and precertification) refers to a requirement by health plans for patients to obtain approval of a health care service or medication before the care is provided. This allows the plan to evaluate whether care is medically necessary and otherwise covered.
Best practices for reducing claims denied for prior authorization Appeal then head back to the beginning. Plan for denials. Double check CPT codes. Take advantage of evidence-based clinical guidelines. Clearly document any deviation from evidence-based guidelines.
What happens if prior authorization is denied? If your insurance company denies pre-authorization, you can appeal the decision or submit new documentation. By law, the insurance company must tell you why you were denied. Then you can take the necessary steps to get it approved.
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.

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A prior authorization decision may take up to 24 to 72 hours. How do I check the status of a prior authorization request? You can call the Member Services phone number on your member ID card from 7 a.m. to 7 p.m. Pacific time, Monday through Friday, or you can call your doctors office.
Who is responsible for obtaining prior authorization? The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patients insurance provider.
Following up on prior authorizations in a timely manner can help alleviate some of the delays in obtaining an authorization and providing patient care. Create A Follow Up Plan With Your Staff. Be Methodical About Working Authorizations. Ask For An Estimated Turnaround Time For The Completion Of An Authorization.

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