Prior authorization is the most time-consuming and frustrating administrative process in medicine. This guide covers everything โ from how it works to how to handle denials and appeals effectively.
What Is Prior Authorization?
Prior authorization (PA) โ also called pre-authorization, pre-certification, or pre-approval โ is a process where a healthcare provider must get approval from a patient's insurance company before providing a specific service, medication, or procedure in order to be reimbursed.
Which Services Typically Require Prior Authorization?
- Most brand-name and specialty medications
- Elective surgical procedures
- Advanced imaging (MRI, CT scan, PET scan)
- Specialty referrals (to specialists outside the primary network)
- Inpatient admissions
- Physical therapy and rehabilitation services
- Durable medical equipment (DME)
- Home health services
The Prior Authorization Process Step by Step
- Identify requirement: Confirm if the ordered service requires PA for the patient's specific plan
- Gather clinical documentation: Medical necessity documentation, prior treatment history
- Submit to payer: Via payer portal, fax, or phone (depending on payer)
- Track status: Check portal or call payer for status updates
- Receive decision: Approved, denied, or pended for more information
- Communicate to patient: Notify of approval or denial immediately
- Schedule service: Once approved, schedule within the authorization window
Average Prior Auth Turnaround Times by Payer
| Payer | Routine Auth (days) | Urgent Auth (days) |
|---|---|---|
| Medicare Advantage | 3โ7 days | 1โ3 days |
| United Healthcare | 3โ5 days | 1โ2 days |
| Aetna | 3โ5 days | 24โ48 hours |
| Blue Cross Blue Shield | 5โ7 days | 24 hours |
| Medicaid (varies by state) | 5โ14 days | 2โ3 days |
Offload Your Entire Prior Auth Workflow
Our VMAs handle all prior authorizations from submission to follow-up โ while you focus on patients.
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