Medigy: Prior Authorization

Prior authorization (PA) is a process used by health insurance companies to determine whether a specific medical service or treatment is medically necessary and covered under the patient’s insurance plan. This usually happens before the service is provided. It is a way for the insurance company to control costs and prevent unnecessary utilization of healthcare services.

Prior authorization can be required for a variety of medical services and treatments, including prescription drugs, medical procedures, durable medical equipment, and certain types of diagnostic tests.

The process of prior authorization can vary depending on the insurance company and the specific service or treatment, but it typically involves the healthcare provider submitting a request for authorization to the insurance company, along with supporting documentation such as medical records, laboratory results, and treatment plans. The insurance company will then review the request and make a determination of medical necessity based on established criteria.

Prior authorization can be a time-consuming and labor-intensive process for healthcare providers, and it can also lead to delays in care for patients. In addition, there are concerns that prior authorization can limit access to care and impede continuity of care.

Overall, prior authorization is a process used by health insurance companies to determine whether a specific medical service or treatment is medically necessary and covered under the patient’s insurance plan. It is a way for the insurance company to control costs, but it can also lead to delays in care and impede continuity of care.