02 — Capability · BC-1810.40
Prior Authorization
Obtain the payer approvals a planned service requires before it is performed, as the provider requesting them, and keep the service, the approval and the claim in step. Reviewing and deciding the request is the health plan's utilization management.
- Prior Auth
- Precertification
- Preauthorization
- Provider Authorization Requests
In scope
- Determining which services and payers require authorization
- Medical and pharmacy-benefit requests with supporting documentation, including electronic prior authorization
- Tracking status, expirations, extensions and changes to the authorized service
- Following up on denials, including peer-to-peer review requests
Out of scope
- The payer's review and decision on the request (see BC-1870.50)
- Appealing a denied claim after the service (see BC-1840.40)
- Benefits investigation and authorization by a specialty pharmacy for the drugs it dispenses (see BC-1830.30)
Realized by · 2
- Epic · Payer-Provider Exchangepartial via BC-1810.40.20
- MEDITECH Expanse · Electronic Prior Authorizationpartial via BC-1810.40.10
Used in · 2
Build it · 1
- technology Healthcare Claims Clearinghouses & Billing Systems via BC-1810.40.20
Decomposes into · 4
- BC-1810.40.10Authorization Requirement CheckDetermine for each order and payer whether authorization, notification or a referral is required, using maintained payer rules rather than memory.
- BC-1810.40.20Authorization Request SubmissionAssemble the request with the clinical information the payer asks for and submit it by portal, electronic transaction or fax, early enough not to delay care.
- BC-1810.40.30Authorization Status TrackingFollow every pending request to a decision, record the approved service, units and dates, and catch expirations and changes before the patient is treated.
- BC-1810.40.40Authorization Denial Follow-UpAct on a denied or partly approved request by arranging a peer-to-peer discussion, resubmitting with more information or rescheduling, and tell the patient what it means for them.