Insurance companies require prior authorization for various reasons, including age, medical need, the availability of a generic alternative, and drug interactions. A rejected approval might result in the denial of a requested service or the patient being forced to go through a different procedure termed “step therapy”. Step therapy states that a patient must first experience failure with medication or service recommended by the insurance provider, often regarded as more cost-effective before the insurance company will cover an alternative treatment.
Medical Billing Authorization
In medical billing, authorization relates to the procedure through which the payer agrees to cover the recommended services before they are given. Pre-authorization or prior authorization services are other terms for this. As the term implies, approval from the insurance payer is required for the proposed treatment or services.
Specific methods necessitate pre-authorization from the insurance provider. Insurance companies pre-authorize the request based on the benefit terms and required medical procedures. The insurance provider issues a pre-authorization number, which must be referenced in the final claim form, and submitted once the treatment is done.
Is It Necessary To Obtain Approval or Authorization From My Insurance Company Before Receiving Medical Care?
You do not need the authorization to seek emergency care if you are experiencing a medical emergency. A sick or wellness visit with a primary care provider does not seek consent or approval under most health plans.
Prior authorization from your insurance company is not the same as a referral from your primary care physician. Some services necessitate prior approval as well as a referral. Prior authorization allows an insurance company’s clinical team to study treatment protocols, access health care providers, and contribute to the course of therapy. Prior approval may determine whether a health care service, treatment plan, prescription medicine, or durable medical equipment is medically appropriate. It may also be used to initiate cooperation between a nurse case manager and the health care providers from whom you will receive treatment. Prior authorization does not guarantee that your insurance company will pay the total cost of permitted services.
The following are some of the more typical healthcare procedures that may necessitate prior authorization:
- Admission to a hospital or skilled care facility is planned.
- MRIs and CT scans are examples of advanced imaging.
- Donor and transplant services
- Air ambulance transport for non-emergency situations.
- Medical supplies.
- Specialty medication therapies.
How To Obtain Insurance Company Preauthorization?
Pre-authorization applications can be made over the phone, online, or by fax.
The insurance confirmation process is the first step in pre-authorization for an eligibility checking firm or doctor’s office.
Once the patient has been scheduled for a surgery or a healthcare service, you should begin the verification system and check with the insurance company to see if the process or service needs pre-authorization. Start the pre-authorization application if the company says it is required. Include the following details in your request:
- Name, address, mobile number, insurance ID, and insurance status of the patient
- Name, address, phone number, specialization, tax ID number, and National Provider Identifier (NPI) number of the provider
- Explain the services requested, including duration dates and total frequency of customers, and specific CPT/HCPCS codes.
- Diagnosis and the associated ICD codes.
- Pre-Authorization Reason
- The facility where the process is performed (facility’s Tax ID number, NPI number, address, phone number, and fax number).
Medical notes are required along with it. After receiving your request, the insurer may occasionally seek more information to grant pre-authorization.
In that case, you have to provide additional documentation, such as details about previous treatment and the type of service offered. A request can be approved in five to thirty days. If it is a medically urgent need, include the facts in your pre-authorization letter that fits the criteria for an urgent request.
After evaluating your pre-authorization procedure, you can appeal the decision if your request is denied. However, you should seek pre-approval because you need to provide the pre-authorization number with your claims. Unauthorized claims will result in significant income loss. You can rely on insurance authorization services to handle any pre-authorization issues.
Billing Executive – a Medical Billing and Coding Knowledge Base for Physicians, Office staff, Medical Billers and Coders, including resources pertaining to HCPCS Codes, CPT Codes, ICD-10 billing codes, Modifiers, POS Codes, Revenue Codes, Billing Errors, Denials and Rejections.
We have more than 10 years experience in US Medical Billing and hand-on experience in Web Management, SEO, Content Marketing & Business Development with Research as a special forte.