preauthorization

preauthorization

(prē'aw-thōr-i-zā'shŭn),
A prerequisite, often intended as a rate-limiting or cost-containment step, in the provision of care and treatment to an insured patient. A practitioner who expects to be paid for a service must use paperwork and telephone contact with a designated entity (often clerks, but sometime medical professionals), often a TPA, to determine whether the proposed treatment or procedure is deemed medically necessary for the health and welfare of the covered party.
See also: benefit, health maintenance organization, managed care, fee-for-service insurance, traditional indemnity insurance.

preauthorization

Managed care The requirement by an HMO that a costly surgery, specialist referral or non emergency health care services be approved by the insurer before it is allowed. See HMO.

pre·auth·or·i·za·tion

(prē'awth'ŏr-ī-zā'shun)
In the U.S., authorization of medical necessity by a primary care physician before a health care service is performed. A referring health care provider must be able to document why the procedure is needed. It does not guarantee coverage.
See also: assignment

pre·auth·or·i·za·tion

(prē'awth'ŏr-ī-zā'shun)
In the U.S., authorization of medical necessity by a primary care physician before a health care service is performed. A referring health care provider must be able to document why the procedure is needed. It still does not guarantee coverage.
References in periodicals archive ?
Although imaging in ED was not subject to the EUM, it might be somehow discretionary and therefore potentially influenced by the EUM if patients shifted to ED to avoid constraints of the preauthorization process, offsetting the reductions from the settings subject to the EUM.
Every year there are more policies, rules, regulations, penalties, coding changes, audits, deadlines, and forms to complete that roll out like an avalanche and take time away from our patients, not to mention the time required to obtain preauthorization and precertification of many procedures.
The reforms in 2007 increased maximum statutory benefits, limited the number of weeks of permanent partial disability (PPD) payments, created medical treatment guidelines, adopted a fee schedule for pharmaceuticals, established networks for diagnostic services and thresholds for preauthorization, and enacted administrative changes to increase speed of case resolution.
The requirement will impact Cigna customers whose health plans require preauthorization.
Medicare patients who meet admission criteria do not require preauthorization.
In addition, insurance companies may require preauthorization before the performance of certain tests, and this is particularly true of germ-line testing.
(11) Commercial insurance companies have also taken an increasing interest in controlling advanced imaging with preauthorization schemes proliferating throughout the country.
In Illinois, the Department of Healthcare and Family Services has excluded 17 drugs from its preferred drug list (including Abilify), requiring physicians to call or send in a fax to obtain preauthorization. In a state that spends $180 million annually on atypical antipsychotics alone, this move could potentially save $90 million in the first year.
While the time spent in direct engagement between representative and clinician can be costly, it pales in comparison to the cost incurred by the office staff dealing with preauthorization for prescriptions written for non-formulary drugs.
The medical auditor can quickly search for the preauthorization approval and compare it with the bills.