In Authorizations, Insurance Verification

If you run a medical practice, there may be situations where you need to get the benefits of a prior authorization from the insurance company before performing a particular service. The vast majority of healthcare plans 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 essential 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?

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

What Services Require Prior Authorization?

Significantly, the same services that require accurate time insurance verification 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 costly, and insurance companies do not want to pay for them unless needed.
  • CT and CTA Scan: Although CT and 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, commonly used to diagnose and stage cancer, often require prior authorization. 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 necessary for people with chronic medical conditions or for people 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 approval, 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. Everyone needs to look at the details of their health plans to understand what options require prior approval.

How Can Doctors Make This Process Easier?

It can take a long time for practices to compile the necessary documentation 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 with a lot of experience working with prior authorization claims for insurance companies, they can streamline the process. A specialist will ensure that the claim is filed with the correct department at the right 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 before submitting the authorization request. This can help the practice save time while getting patients the necessary care. After all, the doctor understands the most medically essential 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 unparalleled 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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