What does "prior authorization" require from healthcare providers?

"Prior authorization" involves obtaining approval from payers before a healthcare provider delivers certain services or medications to a patient. This process is crucial as it helps ensure that the proposed treatment is medically necessary and covered under the patient's insurance plan. By requiring prior authorization, payers aim to manage costs and ensure that healthcare services align with clinical guidelines and best practices.

In the context of the healthcare reimbursement process, this step can prevent unexpected denials of payment after services have been rendered, reducing financial risk for both the provider and the patient. This makes it essential for healthcare providers to understand which services require prior authorization and to complete the necessary paperwork accurately and in a timely manner.

Other options, such as submitting a payment request or notifying patients of treatment options, do not correctly capture the essence of what prior authorization entails. Prior authorization specifically refers to obtaining payer approval prior to the commencement of treatment, not after the services have been provided or regarding patient communication about treatment alternatives. Similarly, scheduling a follow-up appointment is not related to the prior authorization process.