Prior authorization

Prior authorization is the payer’s utilization control. The practice submits the patient’s coverage, the requested CPT or HCPCS codes, the diagnosis and the clinical notes that meet the payer’s criteria; the payer returns an approval with an authorization number, the approved codes, units and date range, or a denial with its reason. Which services need it varies by payer and plan, and the lists change, so the payer’s provider portal or manual is the only reliable reference. A referral is not an authorization, and a payer saying a service is covered is not an authorization either.

An authorization denial is one of the few denials that documentation cannot fix after the fact. The payer’s position is that it was never asked. Some payers allow a retroactive authorization in defined situations, an emergency admission or retroactive eligibility, but scheduled care rarely qualifies. The denial also spreads: the facility claim, the anesthesia claim and any other claim tied to the same service often deny with it.

The mistake is recording authorization obtained without recording what was authorized. The approval has to match the code billed, the units, the dates, the site of service and the rendering provider or group. Put the authorization number on the claim, keep the approval document with the account, and check the approved dates again when the schedule moves.