What is pre-authorization for insurance?

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification.

Why do insurance companies require pre-authorization?

Why does my health insurance company need a prior authorization? 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.

What is a prior authorization managed care?

Prior authorization—sometimes called precertification or prior approval—is 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.

Which type of service may require an authorization from the insurance company?

Examples of the more common health care services that may require prior authorization include: Planned admission to a hospital or skilled nursing facilities. Surgeries. Advanced imaging, such as MRIs and CT scans.

How long does pre-authorization take?

How Long Does a Prior Authorization Take to Get? Once your physician submits a request for prior authorization, a decision is usually returned in several days. In some instances, the initial request may take as long as a week, and appeals may take even longer.

What does pre authorized mean?

A pre-authorization is a restriction placed on certain medications, tests, or health services by your insurance company that requires your doctor to first check and be granted permission before your plan will cover the item.

Why is it important for the healthcare professional to know when a preauthorization is required?

Depending on what the patient’s coverage documents and the provider’s contract with the insurer say, neglecting to obtain preauthorization can result in reduced reimbursements or lower benefits for the patient. Services that don’t require preauthorization can be subject to review in some cases.

What is the difference between a referral and a pre-authorization?

A referral is an order from your PCP to see a specialist or receive certain medical services from some providers. Your PCP helps make the decision about whether specialist services are necessary for you. Prior authorization is approval from the health plan before you get a service or fill a prescription.

What is the difference between pre-authorization and pre-certification?

Unlike pre-certification, pre-authorization requires medical records and physician documentation to prove why a particular procedure was chosen, to determine if it is medically necessary and whether the procedure is covered.

What is the difference between a prior authorization and a pre determination?

This authorization is simply to tell you whether or not the patient’s policy covers a specific treatment, but it does not tell you how much coverage they have. Once you receive preauthorization, you can then complete request to receive more specific information about their coverage this is the predetermination.