Pre Authorization

Pre Authorization is also referred as prior authorization or pre certification or Prior approval.

It is a check used by the Insurance companies or third party payers before the health care service provided to the patient by providers.

Pre Authorization is the process that health care providers has to determine if the health insurance company will cover a specific treatment, device, procedure, supply, prescribed drug or service and also make sure to obtain advance approval (Pre Authorization number) from insurance before the services delivered to the patient.

In the other way we can say health care physicians has to obtain proper permissions (Pre Authorization Number) from Health Insurance Company before the health care services rendered to the patient.

Pre Authorization must be obtained in prior, in order to qualify for the payment for the services which requires authorization and the process to obtain varies from insurance to insurance.


Why Health Insurance Company require Pre Authorization?

Pre Authorization is required to optimize patient outcomes by ensuring that they receive the most appropriate Medical services or Prescriptions. This process is intended to act as a cost saving and safety measure.

The main purpose of pre authorization is to prevent unnecessary services or Medication. Insurance company want to make sure that the Medical Services or Prescriptions doctor requesting is medically necessary before the service rendered or prescribed to patient.


What kinds of Drugs need pre authorization?

  • Suppose Doctor prescribing of expensive brand name drugs, when an appropriate generic is available for cheap that might work better. For example: Consider Drug B (Expensive) and Drug C (Cheaper) both treat your condition, if provider prescribes Drug B. In this insurance company may want to know why Drug C won’t work just as well.
  • Drugs used for Cosmetic services.
  • Drugs is often misused or abused.

Some drugs should be used only for certain age groups or health conditions.

Usage of Higher doses of drugs than normal standard dosage that may have adverse health effects, possibly dangerous interactions

Some Drugs that have dangerous side effects or can be harmful when combined with other drugs.

  • Drugs that treats non-life threatening conditions.

These are the most important cases why drugs need pre authorization.

In our next article let us learn the methods to obtain pre authorization.

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