Prior authorization (also called pre-authorization or pre-certification) is a requirement by a health plan that certain services, procedures, equipment or medications be approved before they are provided. Without it, the claim is usually denied.
An authorization typically specifies the approved codes, number of units or visits, and a date range. Treating outside those limits can still lead to a denial.
Related terms
- Eligibility verification
- Confirming a patient's insurance is active and what it covers before the visit.
- Medical necessity
- The requirement that a service is reasonable and needed for the patient's condition.
- Claim denial
- A payer's decision not to pay a claim that it received and processed.