Prior authorization is a payer review that may be required before certain items or services are delivered. Requirements differ by plan, service, diagnosis, place of service, and other factors, so teams need a current source of truth rather than a static memory-based list.
Information to capture
- The plan and member information checked.
- The service, code, diagnosis, provider, and location submitted.
- The documentation included with the request.
- The reference number, status, effective dates, and approved units.
- Any request for additional information and its deadline.
- The decision, appeal route, and communication sent to the patient.
Avoid a common communication mistake
An authorization is not always a guarantee of payment. Coverage can still depend on eligibility, benefits, medical-necessity rules, claim accuracy, coordination of benefits, and other terms. Explain this distinction clearly and avoid promising a final patient amount before the payer processes the claim.
Primary reference: CMS explains current Medicare prior-authorization and pre-claim review initiatives on its official program page. Use the relevant payer’s current requirements for each case.
