Understanding Prior Authorizations

June 12, 2018 | Holly

Understanding Prior Authorizations:

Many insurance plans require services to be authorized ahead of time.  After we determine a service requires prior authorization, we will need to determine how to achieve this.  Each plan is unique.  Many accept phone calls, and many require we fill out and submit their own form.  Sometimes there will be a web portal they prefer us to use.

Be aware that even when insurance plans issue prior authorization, this does not mean they are bound to cover the service.  The plans will sometimes find other ways not to pay claims by stating a variety of reasons such as – the provider is not credentialed with that insurance, or those services are not listed as part of the existing contract which the provider has with the insurance, or even sometimes the patient’s coverage termed before the date of service occurred.  So really pay attention to the overall picture and the details when it comes to prior authorizations.  And yes, it is very true that they will issue prior authorization even when there are circumstances (such as those named above) that may prevent the payment from ever being issued.

Pre Authorizations Commonly Contain:

  1. code(s) they are authorizing
  2. start date and end date
  3. number of visits allowed
  4. provider name
  5. patient name (and maybe date of birth and insurance policy #)
  6. pre-authorization number

Pre-authorizations should always be in written form.  If we don’t have a document – it is like not having a pre-authorization because there is then no way to prove it later.  Verbal is sometimes given by phone…. but then we should ask to receive the written document to back it up.  Hopefully the software being used will be able to track these visits, otherwise, a staff member will need to keep track and if more visits are required it may be necessary to request another prior authorization.