Prior Authorization Certification and Its Impact on Healthcare

Prior authorization certification has become a critical component of the healthcare system, affecting patients, providers, and payers alike. It's a process that requires healthcare providers to obtain approval from payers before administering certain treatments or medications.

In the United States, 96% of health plans require prior authorization for at least one service. This means that healthcare providers must navigate a complex approval process for many of their patients.

The impact of prior authorization certification can be significant, with studies showing that it can lead to delays in treatment, reduced access to care, and increased administrative burdens on healthcare providers.

Precertification is a crucial step in the prior authorization process. It involves a prior authorization review for inpatient admissions, unless the admission is for a medical emergency, a life-threatening condition, for obstetrical care, or occurs outside the 50 United States.

You can submit a precertification request or view the status of an existing request by visiting the secure pre-certification section. This is a required step for inpatient medical stays, which can be done with a secure login through Availity.

To contact Availity for inpatient medical stays, call 800-782-4437. For inpatient mental health stays, call 800-952-5906.

Some group health plans may have different terms of coverage or benefits, so it's essential to verify coverage or benefits and determine precertification or authorization requirements by calling 800-676-BLUE or sending an electronic inquiry through your established connection with your local Blue Plan.

Earning a prior authorization certification can boost your earning ability and make you more marketable in the job market.

Online courses are available to help you build a strong foundation in understanding medications and developing clinical reasoning skills.

By learning to speak medicine, you can gain a competitive edge in your career.

Having the right certifications can significantly impact a prior authorization specialist's career and salary. The most common combination of certifications include Certified Pharmacy Technician (CPhT), Medical Assistant, and Certified Billing and Coding Specialist (CBCS).

Earning a Certified Pharmacy Technician (CPhT) certification can be a great starting point, but it's often paired with other certifications to increase earning potential.

A Medical Assistant certification can also be beneficial, but it's often combined with other certifications to maximize career opportunities.

Certified Billing and Coding Specialist (CBCS) certification is another valuable addition to a prior authorization specialist's toolkit.

Access control is a crucial aspect of ensuring patients have access to necessary medications. Some medications require prior authorization, which can be a lengthy process.

Germline genetic testing for hereditary breast/ovarian cancer syndrome and other high-risk cancers, such as BRCA1 and BRCA2, is an example of a medication that requires prior authorization. This testing is typically only approved for patients with a family history of these cancers.

The prior authorization process can be completed electronically through CoverMyMeds for most medications. This streamlined process helps reduce the administrative burden on healthcare providers.

If a medication is not on the list of covered drugs, patients may still be able to access it through the prior authorization process. However, this may require additional documentation and approval.

Here are some examples of medications that require prior authorization:

For patients with BCBSKS insurance, prior authorization forms can be found through the following links:

To prepare for a career as a prior authorization specialist, it's essential to learn medical coding. This skill will serve you well in today's healthcare workplace.

Medical coding is a crucial aspect of prior authorization, as it helps ensure that patients receive the necessary care and services.

If you're considering a career as a prior authorization specialist, having the right certification can make all the difference. The Certified Pharmacy Technician (CPhT) certification is a top choice, according to various sources, including Zippia Careers and active job postings.

According to the PTCB, the organization that offers the CPhT certification, having this credential can give you access to more prior authorization specialist jobs with higher salaries. I've seen firsthand how having the right certification can open doors to new opportunities.

The CPhT certification requires passing an exam and meeting certain education and training requirements. It's a great way to demonstrate your expertise and commitment to the field.

Here are the top 9 certifications for prior authorization specialists, based on various sources:

These certifications can help you stand out in the job market and demonstrate your expertise in areas like medical coding, billing, and pharmacy.

If you're looking to boost your career as a prior authorization specialist, getting certified is a great place to start. The most in-demand certification is the Certified Pharmacy Technician.

Having this certification will give you access to more prior authorization specialist jobs with higher salaries. You can earn this certification through online courses and training programs.

For those who want to explore other options, the Certified Medical Administrative Assistant (CMAA) certification is also worth considering. This certification requires passing an oral or written exam.

Here are some key facts about the CMAA certification:

These certifications can help you develop the skills and knowledge you need to succeed as a prior authorization specialist.

Precertification and prior authorization are a checks and balances system to ensure proper use of insurance benefits and control the risk of fraud and inappropriate use.

They help keep the cost of health care premiums affordable for everyone.

Pre-service requests are a courtesy review performed by BCBSKS to determine coverage for services, supplies, or prescription drugs that have a medical policy or are high-cost.

Prior authorization is required for inpatient services.