According to the American Medical Association, Prior authorization (PA) is any process by which physicians and other healthcare providers must obtain advance approval from a health plan before a specific procedure, service, device, supply, or medication is delivered to the patient to qualify for payment coverage. Other terms used by health plans for this process include “pre-authorization,” “precertification,” “prior approval,” “prior notification,” “prospective review,” and “prior review.”

Many medical treatments need approval or pre-certification to be covered by the insurance company. However, the lack of standards for the information required and EDI standards for data exchange make the pre-certification process tedious and time-consuming, requiring experts with payer-specific knowledge to support clinicians in the delivery of care.

Benefits Of Prior Authorization