Authorization.pptx Authorization in U.S. healthcare is the process of getting approval from an insurance provider before receiving a medical service. It's also known as prior authorization, pre-authorization, or precertification.

Authorization
US Healthcare

1. Authorization US Healthcare

2. Authorization Authorization is a legal obligation to ensure that the insurance payer pays for the specific medical service mentioned in the medical claim form. Without authorization, the insurance payer is free to refuse the payment of a patient’s medical service as part of the health care insurance plan. Authorization involves the collection of information and data that a plan uses not only to make particular decisions but also to monitor utilization and promote quality and cost-effective care.

3. The Purposes of Authorization Authorization helps to ensure that benefits are paid correctly. Quality and cost-effectiveness are promoted in part through clinical practice guidelines.

4. Authorization Four major authorizations are to be obtained by the Provider/Member from the Payer before providing/rendering the medical service. They are: Referral Authorization Prior Authorization/Pre-Certification/Prospective Authorization Concurrent Authorization Retro Authorization

5. Authorization Referral Authorization: A request from a health care provider to a health plan to obtain authorization for referring an individual to another health care provider. A referral is used by a primary care physician (PCP) for the patient to see a specialist. Prior Authorization: Authorization in medical billing refers to the process wherein the payer authorizes to cover the prescribed services before the services are rendered. This is also termed pre-authorization or prior authorization services. Prior authorization (prior auth or PA) is a management process used by insurance companies to determine if a prescribed product or service will be covered. This mean that the product or service will be paid for in full or in part. This process can be used for certain medications, procedures or services before they are given to the patient. Concurrent Authorization: The concurrent review takes place while the patient is receiving care while admitted to the facility. The purpose of the concurrent review is to put an oversight (supervision) process in place that permits the scrutiny of the type of care being delivered, the necessity for that care, and the level and setting of that care. Retro-Authorization: Retro active authorization are given when the patient is in a state (unconscious) or under extenuating (justifying) circumstances where necessary medical information cannot be obtained for pre-authorization. Retro active authorization requests may also be used when: The healthcare provider lacks time to obtain prior authorization If a claim is denied based on medical necessity

6. Authorization Referral Process – Participating Provider PCP will diagnose the patient and if he feels that there is a requirement for the specialist’s intervention then he will fill out the referral form. PCP will fill the referral and it will be issued to the patient once it is approved by the insurance. If the referred specialist feels that another specialist needs to examine the patient, then the PCP must be consulted.

7. Authorization Referral Process – Non-participating Provider In the case of a non participating provider, patient has the responsibility of obtaining a referral. The patient will fill a request to the insurance for approval. Insurance will verify the request and if there is any requirement for specialist intervention then they will approve the request. The approved request will be issued to the patient which can be taken to the specialist. Referral services are subject to member eligibility and the benefits available through the member’s plan. Therefore, a referral authorized by a PCP should not be considered a guarantee of payment.

8. Authorization The following information must be included on the referral form: Member’s name and Id number Provider name Diagnosis Reason for referral Any restrictions Date span of services Number of visits PCP’s name

9. Authorization - Form

10. Authorization Conditions when referral form is not required: When a PCP sends a patient to a speciality provider, the PCP must complete a referral form Referral forms are not required for the following: Pathologist Radiologist Dermatologist Gynaecologist Services rendered by a PCP backup physician Paediatrician

11. Authorization Prior Authorization/Prospective review/Precertification The insurance requires a provider to obtain a prior authorization before performing any – High Cost (example: MRI, CT Scan, Surgery, Chemotherapy) Any new technology and Long term medical treatment (example: long hospital stay, cancer treatment, all chronic diseases) The Provider submits a treatment plan to a utilization review department and must get that authorized before rendering the treatment. This approval is essential for the Provider to receive payment from the insurance because it prepares the insurance for the respective costs, which are to be reimbursed to the Provider. The Utilization Review department from the Payer will provide the Prior Authorization Number to acknowledge the approval. While billing the claim the Provider mentions the Prior Authorization number in the claim.

12. Authorization Prior Authorization Process for Participating Provider In the case of the Participating Provider, whenever the Provider performs services that are of high cost and medically necessary services needs to obtain approval from the Insurer. Physicians need to file a request form. The Insurance will verify the request and depending upon the condition of the patient and verifying the medical necessity, they may either approve or deny the request or approve by making some changes to the request. Once the request is approved the status will be communicated to the physician whereby the Provider will continue the services.

13. Authorization Prior Authorization Process for Non-Participating Provider In the case of a non-participating physician, the patient will take full responsibility for obtaining prior approval from the Insurance Patient will file the request to the Insurance Insurance will verify the request and communicate the outcome to the patient With the prior approval from the insurance patient continues with the services In case the patient failed to obtain prior approval, then the patient needs to take the responsibility of reimbursing the physician

14. Authorization The following information is required to file a Prior Authorization request – Patient demographic details, ID number, and DOB Ordering Physician name, NPI/TIN Rendering Physician Name, NPI/TIN * Rendering Facility name, NPI Type of Procedure (CPT/HCPCS) Unit/Volume of Procedure Whether the request is Emergency/Urgent/Elective Primary Diagnosis Code * Planned date of services (From date to End date) Place Of Services

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