Prior authorization

Prior Authorization

Prior authorization (pronunciation: /praɪər ɔːθərɪˈzeɪʃən/), also known as pre-authorization or pre-certification, is a process used by health insurers or managed care organizations to determine if they will cover a prescribed procedure, service, or medication. The process is intended to act as a safety and cost-saving measure, although it has been criticized for adding complexity to the healthcare system.

Etymology

The term "prior authorization" originates from the insurance industry and refers to the requirement that certain services or medications must be approved, or "authorized," by the insurer "prior" to being provided or prescribed.

Process

The prior authorization process begins when a healthcare provider submits a request to the insurer for a service or medication they believe is necessary for their patient. The insurer then reviews the request and determines whether it meets their coverage criteria. If the request is approved, the service or medication is covered under the patient's insurance plan. If the request is denied, the service or medication is not covered, and the patient may be responsible for the cost.

Related Terms

• Medical necessity: A concept used by insurers to determine if a service or medication is necessary for a patient's health.
• Utilization management: The process used by insurers to review the appropriateness and efficiency of healthcare services.
• Appeal: The process a patient or provider can initiate if they disagree with an insurer's decision to deny coverage.

Criticism

Critics of prior authorization argue that it can delay care, increase administrative burden for providers, and potentially lead to negative health outcomes if necessary services or medications are denied. Some also argue that it gives insurers too much control over patient care decisions.

See Also

• Health insurance
• Managed care
• Healthcare system
• Medical necessity
• Utilization management
• Appeal

External links

• Medical encyclopedia article on Prior authorization
• Wikipedia's article - Prior authorization

This WikiMD dictionary article is a stub. You can help make it a full article.

---

Languages: - East Asian 中文, 日本, 한국어, South Asian हिन्दी, Urdu, বাংলা, తెలుగు, தமிழ், ಕನ್ನಡ,
Southeast Asian Indonesian, Vietnamese, Thai, မြန်မာဘာသာ, European español, Deutsch, français, русский, português do Brasil, Italian, polski