Question

explain Securing a Prior authorization and discuss the process steps involved in the Medical assistant or other health care provider with the task. Respond to two students who posted a discussion on a topic different from the one that you selected. Responses must be substantial. Read all discussion.

Answer 1

Prior authorization is a health plan cost-control process by which health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient in order to qualify for payment coverage.

It is a characteristic of utilization management, in which an insurance payer looks at a several factors like prior treatment, medical necessity, clinical indications, and total therapy cost for cost saving.

The process of prior authorization involves the following steps:

1) The patient need for a specific procedure, test, medication or device is identified by the health care provider.

2) It is the responsibility of the provider to check a health plan’s policy rules to find out if a prior authorization is required for the prescribed course of treatment. If so, the provider should submit a prior authorization request form and sign it for attesting the information supporting the medical necessity claim.

3) The health care provider will review prior authorization rules for the specific insurance plan associated with the patient. The rules can differ in various health plans.

4) Next, tracking of specifics about each CPT code that is applicable to the prescribed course of treatment is required.

5) The health care provider is responsible to follow up with the insurance company until the prior authorization request is resolved. This will involve an approval, redirection, or denial.