Understanding Insurance Prior Authorization Process

1
Understanding Insurance Prior
Authorization Process
2
Understanding Insurance Prior Authorization
Process
Basics of Insurance Prior Authorization Insurance
prior authorization is a process that is commonly
used by insurance companies to determine whether
a specific medical service or treatment is
necessary and appropriate for a patients medical
condition. It is a process that is designed to
control healthcare costs and ensure that patients
receive the appropriate level of care. The
insurance prior authorization process typically
begins when a healthcare provider submits a
request to the insurance company for a specific
medical service or treatment. The insurance
company then reviews the request and makes a
determination about whether the service or
treatment is medically necessary and covered
under the patients insurance plan. If the
insurance company determines that the service or
treatment is not medically necessary or not
covered under the patients insurance plan, it
may deny the request. In some cases, the
insurance company may require additional
information from the healthcare provider before
making a decision. Insurance prior authorization
can be a time-consuming process, and it can delay
the delivery of healthcare services to patients.
It can also create additional administrative
burdens for healthcare providers and increase
healthcare costs. Despite these challenges,
insurance prior authorization is an important
tool for insurance companies to manage healthcare
costs and ensure that patients receive
appropriate and effective medical care.
3
Understanding Insurance Prior Authorization
Process

• Other Names of Insurance Prior Authorization
• There are several other names used to refer to
  prior authorization in medical billing. These
  terms are often used interchangeably and refer to
  the process of obtaining approval from an
  insurance company or healthcare payer before a
  medical service or procedure is provided. Some of
  these include
• Preauthorization
• Prior approval
• Precertification
• Prior notification
• Prior review
• Utilization review
• Pre-certification
• Pre-admission certification
• Pre-service review
• Prior authorization request (PAR)
• Types of Insurance Prior Authorization
• There are different types of prior authorization,
  including prescription prior authorization and
  medical prior authorization.

4
Understanding Insurance Prior Authorization
Process

• 1. Prescription Prior Authorization
• Prescription prior authorization refers to the
  process of obtaining approval from an insurance
  company or other payer before a prescription
  medication can be filled. The prescriber must
  submit a request for prior authorization, which
  includes information such as the patients
  medical history and the rationale for prescribing
  the medication. The insurance company will review
  the request and may approve or deny the prior
  authorization.
• 2. Medical Prior Authorization
• Medical prior authorization, on the other hand,
  applies to medical procedures, tests, or
  treatments that require prior authorization. This
  may include surgeries, diagnostic imaging tests,
  physical therapy, and other medical procedures.
  The medical provider must submit a request for
  prior authorization, which includes information
  such as the patients medical history and the
  rationale for the procedure. The insurance
  company will review the request and may approve
  or deny the prior authorization.
• 3. Other Category of Prior Authorization
• There may be other types of prior authorization
  required by insurance companies, depending on the
  specific policy. For example, some insurance
  companies require prior authorization for durable
  medical equipment (DME), such as wheelchairs or
  oxygen tanks. Another category of prior
  authorization is behavioral health prior
  authorization, which applies to mental health and
  substance abuse treatments.

5
Understanding Insurance Prior Authorization
Process

• Medications Needing Prior Authorization
• Prior authorization is a process used by health
  insurance companies to ensure that certain
  medications or medical treatments are medically
  necessary and appropriate before they are covered
  by the insurance plan. The specific medications
  and treatments that require prior authorization
  can vary depending on the insurance plan, but
  some examples include
• Specialty medications Expensive drugs used to
  treat complex medical conditions like cancer,
  autoimmune disorders, and rare diseases.
• Imaging tests Advanced imaging tests such as CT
  scans, MRI scans, and PET scans.
• Surgeries Certain types of surgeries that are
  expensive or require special equipment or
  expertise.
• Medical equipment Durable medical equipment such
  as home oxygen, power wheelchairs, and hospital
  beds.
• Behavioral health medications Certain
  medications used to treat mental health
  conditions like depression, anxiety, and bipolar
  disorder.
• Infertility treatments Fertility treatments such
  as in vitro fertilization (IVF) may require prior
  authorization.
• Physical therapy Extended periods of physical
  therapy, especially if it involves expensive
  equipment or multiple visits.
• Its important to note that different insurance
  plans may have different requirements for prior
  authorization, so its always a good idea to
  check with your insurance company to see which
  medications or treatments require prior
  authorization.

6
Understanding Insurance Prior Authorization
Process
Our Insurance Prior Authorization Services Legion
Healthcare Solutions is a leading medical billing
company providing complete billing and coding
including prior authorization services. We
understand that every healthcare provider has
different needs when it comes to prior
authorization. Thats why we offer a range of
services tailored to meet the unique needs of our
clients. Insurance prior authorization can also
be a time-consuming and tedious process, causing
delays in treatment and administrative burdens
for healthcare providers. Thats where Legion
Healthcare Solutions comes in, our prior
authorization services can help healthcare
providers streamline their authorization process,
allowing them to focus on delivering high-quality
patient care. To know more about our insurance
prior authorization services, contact us at
727-475-1834 or email us at info_at_legionhealthcares
olutions.com
7
(No Transcript)