Prior authorization (PA)
Plan approval required BEFORE a service is rendered, otherwise the plan won't pay.
Prior authorization is the process by which a health plan requires the provider to get approval before a service is rendered. The plan reviews medical necessity against its criteria. Without PA, the plan won't pay (CARC 197). Common PA targets: specialty drugs, advanced imaging, inpatient admissions, complex surgical procedures. Emergency services are protected from PA by ACA §2719A and the Prudent Layperson Standard.
Frequently asked questions
What is prior authorization (pa)?
Prior authorization is the process by which a health plan requires the provider to get approval before a service is rendered. The plan reviews medical necessity against its criteria. Without PA, the plan won't pay (CARC 197). Common PA targets: specialty drugs, advanced imaging, inpatient admissions, complex surgical procedures. Emergency services are protected from PA by ACA §2719A and the Prudent Layperson Standard.
Is this relevant to a denial appeal?
PA denials are reversible via formal appeal and external review.
Related terms
- Step therapyA plan requirement to try and fail a cheaper drug before the plan covers the requested drug.
- Peer-to-peer (P2P)A live phone discussion between the prescribing physician and a plan medical director. Often resolve
- Medical necessityThe standard for whether a service is required to diagnose or treat a condition — and the most commo
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