Get Radiology Prior Authorization Program Frequently Asked Questions (faq)

Some procedures or services that may require prior authorization include: all inpatient services and inpatient rehabilitation. mental health care. substance abuse care. sub-acute skilled care. private duty nursing. home health. hospice. high-tech radiology.

These steps are usually done manually, often through a cascade of phone calls, faxes and emails between payer and provider. The responsibility falls on the provider to continue to follow up with the insurance company until there is resolution of the prior authorization request — an approval, redirection, or denial.

Prior authorization specialists usually: Discuss medications, insurance and prior authorization documents with patients. Get prior authorization approval from insurance firms and nurse managers. Appeal insurance companies after prior authorization refusals. Assess accounts for completeness and accuracy.

Prior authorization is one of the most common drug utilization management tools in the U.S. health care system. The intent of prior authorizations is to ensure that drug therapy is medically necessary, clinically appropriate, and aligns with evidence-based guidelines.

These steps are usually done manually, often through a cascade of phone calls, faxes and emails between payer and provider. The responsibility falls on the provider to continue to follow up with the insurance company until there is resolution of the prior authorization request — an approval, redirection, or denial.

What kinds of drugs need prior authorization? Drugs that have dangerous side effects. Drugs that are harmful when combined with other drugs. Drugs that you should use only for certain health conditions. Drugs that are often misused or abused. Drugs that a doctor prescribes when less expensive drugs might work better.

Prior authorization can be used for medications that have a high potential for misuse or inappropriate use. For some categories, health plans may limit the coverage of drugs to FDA-approved uses and require a prior authorization for off-label indications.

Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.