Effective revenue cycle management depends upon pre-authorization and insurance verification. The prior authorization process facilitates billing processes, payment collection, denial reduction, and constant follow-up for healthcare providers.

It is a requirement that your doctor gets approval from the health plan before the plan will cover the costs of a specific medicine, medical procedure or device. Your doctor will often complete a form to demonstrate to your insurance company that the service you are prescribed is medically necessary. Your insurance company has requirements that must be met before it will approve this service.

Prior Authorization Services Offered by Complete Care Billing

Prior Authorization Services

Complete Care Billing fully recognizes the complexity of preauthorization in medical billing and the insurance prior authorization requirements of our prior authorization services clients. To ensure that all our clients needs are met successfully, our highly qualified and experienced coordinators manage end-to-end communication and authorization, working with government and private insurance companies.

What is Prior Authorization?

Prior authorization or pre-authorization is a utilization management practice used by health insurance companies that require certain procedures, tests, and medications prescribed by healthcare clinicians to first be evaluated to assess the medical necessity and cost-of-care ramifications before they are authorized.

Prior authorization is sometimes called prior approval and pre-certification as well.

Purpose of Prior Authorization

In order to prevent medication that might not be necessary, could interact dangerously with other medications you might be taking, or could be addictive, prior authorization is used. In addition, it allows your insurance company to manage costs for otherwise expensive medications.

When Prior Authorization Is Required?

When you need a complex treatment or prescription, prior authorization is usually required. As coverage cannot be authorized without prior authorization, it is important to start the process as early as possible. Prior authorization may be required if the doctor is not enrolled with insurance or before getting outpatient services in a hospital or hospital-affiliated facility.

Is Prior Authorization Required In Emergency Conditions?

No, prior authorization is not required in case of an emergency. However, coverage for emergency medical costs is subject to the terms of your health plan.

How Long Does A Prior Authorization Take?

The processing time for prior authorization can range from one day to a month depending on the complexity of the request, the amount of manual work involved, and the requirements stipulated by the payer. Both patients and healthcare professionals can be affected if there is a delay in getting prior authorization.

Who Is Responsible For Getting Prior Authorization?

The healthcare provider usually submits a request form to a patient’s insurer to obtain prior authorization. It is the responsibility of healthcare providers to get prior authorization before providing services to patients. However, the patient can also get prior authorization.

How To Get Prior Authorization?

Every plan has a slightly different way of doing this, so make sure to check with your insurance company for those details or you can visit the insurance portal to get the information about the prior authorization process.

You can typically find information on the plan’s website about how to submit or obtain a prior authorization form if one is required. You need to fill out the form and should submit it to the insurance. This process can be online or you can fax or mail it to the insurance. Also, you can contact us for at any time for Prior Authorization Services.

How Does The Prior Authorization Process Work?

Typically, within one week of receiving the prior authorization request, your insurance company will either:

•             Approve your request

•             Deny your request

•             Ask for more information

•             Recommend you to try an alternative that’s less costly, but equally effective, before your original request is approved

You or your health care provider can request a review of the prior authorization response if you are unhappy with it. You have the right to appeal to the insurance if your prior authorization request is denied by the insurance.

Benefits of Outsourcing Prior Authorization Services to Complete Care Medical Billing

Medical practices face the challenging task of obtaining prior authorizations. It takes up a lot of your office’s time and resources and is a challenging and expensive process. As a result, many healthcare systems and hospitals hire an experienced medical billing company which offers Prior Authorization Services.

Our Pre Authorization Services include the following

  • Complete Care Medical Billing offers complete prior authorization services, from initiation to approval as well as retro authorization.
  • We offer complete prior authorization processing, from initiation to approval.
  • We offer regular updates on our secure, HIPAA-compliant site.