In Medical Transcription Services

If you run a medical practice, there may be situations where you need to get prior authorization from the insurance company before performing a particular service. The vast majority of healthcare plans clearly specify what services require prior authorization. Unfortunately, this could take a lot of time away from the primary focus of patient care. Therefore, it is important to take a closer look at what prior authorization means, what services require prior authorization, and how doctors can make this process easier. Learn more about this important topic below.

What Does Prior Authorization Mean?

In a situation requiring prior authorization, before performing the specific drug or test, the doctor has to contact the insurance company to get approval. The insurance company will make sure it is covered by the plan and is medically necessary before deciding whether to approve the service. It can take anywhere from a few days to a few weeks to hear back on the prior authorization. It depends on the insurance company, the nature of the request, and the urgency of the situation.

What Services Require Prior Authorization?

Importantly, the exact services that require prior authorization will depend on the nature of the insurance plan and the company that covers the plan. Some of the most important examples of medical tests, procedures, surgeries, and treatment options that require prior authorization include but are not limited to:

  • MRI and MRA Scans: Anything that requires an MRI or an MRA scan will probably require prior authorization. Scans that need magnetic resonance are very expensive, and insurance companies do not want to pay for them unless they are required.
  • CT and CTA Scan: Even though CT scans and CT angiogram scans are not as expensive as MRIs, many insurance companies will still require doctors to obtain prior authorization before ordering them.
  • PET Scans: PET scans, which are commonly used to diagnose and stage cancer, often require prior authorization as well. PET scans use positron emission tomography to generate their image.
  • Durable Medical Equipment: Any situation where durable medical equipment is required will probably require prior authorization. Durable medical equipment is often required for people who have chronic medical conditions or for people who are recovering from serious injuries.
  • Expensive or Specialty Medications: There are certain situations where prior authorization might be required to order specific medication. Even though routine antibiotics and pain medications usually do not require prior authorization, there are very expensive, specific specialty medications that could require prior authorization.
  • Surgical procedures: Some specialty inpatient or outpatient surgeries will require prior authorizations.

In general, if a diagnostic or treatment option is out of the ordinary or expensive, it might require prior authorization. It is important for everyone to take a look at the details of their health plans to understand what options require prior authorization.

How Can Doctors Make This Process Easier?

It can take a long time for practices to compile the necessary documentation that is required to submit a claim for prior authorization. Fortunately, there are professional prior authorization services that can make it easier.

If doctors partner with a team that has a lot of experience working with prior authorization claims for insurance companies, they can streamline the process. A specialist will make sure that the claim is filed with the correct department at the correct insurance company to process the request.  

A professional service understands the most common documentation required to file a correct authorization claim. They can review documentation and collect any missing information prior to submitting the authorization request. This can help the practice save a lot of time while also getting patients the care they need. After all, it is the doctor who understands what is most medically necessary for the patient.

Count On DataMatrix Medical for Premier Prior Authorization Services

Ultimately, prior authorization can be a very frustrating part of the medical field. On the other hand, there are ways to streamline prior authorization submissions. At DataMatrix Medical, we have an unparalleled level of experience dealing with prior authorization issues for all major insurance carriers. We can help you streamline the process as well. Contact us today to learn more about our services.

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