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Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.
What is a preauthorization requirement?
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.
What does a preauthorization provide and what additional information is good in the PA process?
The prior authorization process gives your health insurance company a chance to review how necessary a medical treatment or medication may be in treating your condition. For example, some brand-name medications are very costly.
Why is it important to get preauthorization?
Ensures that the service or drug the physician is requesting is truly medically necessary. Ensures that the service isnt being duplicated, especially in cases where multiple specialists are involved. Determines whether the ongoing or recurrent service is actually beneficial to the patients care.
What information should be included in a prior authorization claim?
Clinical information specific to the treatment requested that the payer can use to establish medical necessity, such as: Service type requiring authorization. This could include categories like ambulatory, acute, home health, dental, outpatient therapy, or durable medical equipment. Service start date. CPT and ICD codes.
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