What is prior authorization?
Prior authorization, also called precertification or preauthorization, is a payer's approval for a service before it is performed. If a service that requires approval is performed without it, the claim is often denied, and the denial reason is commonly reported as missing precertification or authorization.
Common services that need authorization
- Advanced imaging such as MRI, CT and PET scans
- Surgery and many outpatient procedures
- Durable medical equipment and home oxygen
- Specialty drugs and infusions
- Physical therapy and other therapy beyond set visit limits
- Sleep studies and certain diagnostic testing
Requirements differ by payer and by plan, and they change often, so a service that did not need approval last year may need it now.
How we handle authorizations
- Check requirements. We confirm whether the service needs authorization for that patient's plan during eligibility verification.
- Submit the request. We send the request with the supporting clinical information the payer asks for.
- Track the decision. We follow up on pending requests and record approval numbers, dates and approved units.
- Handle denials and peer reviews. If the request is denied, we help prepare an appeal or a request for peer-to-peer review.
- Match the claim to the approval. When the claim goes out, we confirm that the codes, dates and units match what was approved.
Why it pays off
Getting authorization right avoids denials, rework and write-offs, and keeps patients from being surprised by bills. It also feeds directly into cleaner claims and better denial management results.
Frequently Asked Questions
What if a patient needs urgent care before approval?
Urgent and emergency services have separate rules. We help document the circumstances and, where payers allow it, request retroactive authorization.
Do you handle authorizations for every specialty?
We handle them for the specialties we bill for, including imaging-heavy practices like cardiology and orthopedics. Tell us what your payers require.
Can authorizations be done separately from billing?
Yes. Many practices start with authorizations and eligibility and add billing later.
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