While Prior Authorization is not a guarantee of payment, it is an extremely important step in ensuring that authorization and medical necessity requirements are met days in advance of the visit. Establishing a strong Prior Authorization process is critical to patients receiving care in a timely manner, provider satisfaction and eliminating the chance of other denials i.e. medical necessity, frequency etc.
Our authorization process includes the following:
- Visit dates should be within the effective and expiration date of the authorization
- Some payers require a specific appointment/visit date
- Appropriate CPT and HCPCS codes are submitted
- Appropriate levels are submitted
- Diagnosis codes meet payer medical necessity guidelines
- Plan of Care is well established and documented
- Diagnosis codes are well documented
- When applicable, the patient has undergone conservative treatment/therapy
- When applicable, MRIs are performed and interpreted
- When applicable the patient has had a psychological evaluation
- Establishing Peer-to-Peer reviews
We work closely with providers to educate them on payer policy changes and prior authorization requirements. We also educate providers on the importance of documentation as it allows for quick authorization approvals and reduces the chances of authorization denials upon submission.