Understanding Prior Authorization Process Flow Chart in Healthcare

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Posted Jan 1, 2025

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The prior authorization process flow chart is a complex system, but understanding how it works can make all the difference in getting the care you need. The process typically starts with a healthcare provider submitting a request to the patient's insurance company.

This request is usually made through an electronic prior authorization system, which streamlines the process and reduces paperwork. According to the flow chart, the insurance company has a specific timeframe to review and respond to the request, which varies by state and insurance provider.

The patient's insurance coverage and the specific treatment or medication being requested also play a crucial role in determining the outcome of the prior authorization process.

Client Eligibility and Requirements

To determine if a client is eligible for a service, log into ProviderOne to check their eligibility. This will help you understand what services they can receive and what requirements need to be met.

If a client is in a managed care plan, you'll need to contact the plan directly to learn about coverage and prior authorization requirements. To access other health plans, visit OneHealthPort.

Before submitting a request for prior authorization, review the policy using your provider billing guides and fee schedules to see if a code or service requires authorization.

Check Client Eligibility

Credit: youtube.com, Eligibility Checker: Medical insurance eligibility & benefits verification

To check client eligibility, log into ProviderOne to see if your client qualifies for the services or treatments you want to provide.

You can learn more about using ProviderOne with the Successful eligibility checks using ProviderOne fact sheet.

If your client is in a managed care plan, you'll need to contact the plan for coverage and prior authorization requirements.

To access other health plans, visit OneHealthPort.

Step 2: Determine Requirements

Before you start the prior authorization process, you need to determine if the treatment or service requires prior authorization. This is crucial to avoid any delays or denials later on.

Check the provider billing guides and fee schedules to review policy and find out whether a code or service requires prior authorization. HCA's authorization services do not consider National Correct Coding Initiative (NCCI) guidelines when processing a request, so make sure your office checks the NCCI guidelines prior to submission.

The payer will check if the drug or service is truly needed as per the patient's condition. They will also evaluate if the recommended drug or service is necessary for the current situation, and if it makes financial sense.

A female doctor using a laptop in a modern healthcare office setting.
Credit: pexels.com, A female doctor using a laptop in a modern healthcare office setting.

Here are some key questions to ask:

  • Is the drug or service required?
  • Is the recommended drug or service necessary for the situation?
  • Does the prescribed drug or service make financial sense?
  • Is there a duplicate service suggested?
  • Is the recurring service benefiting the patient?

If the answer to any of these questions is no, the payer might reject the authorization.

What's the Difference Between a Lead and a Referral?

A referral occurs when a referring provider recommends a patient to another provider to receive care, often in another specialty.

This requires that the ordering provider submit paperwork to authorize the appointment. In contrast, a lead is not a formal recommendation, but rather an interest expressed by a potential client in your services.

Leads and referrals both have the potential to result in new business, but they differ in their level of commitment and the next steps required.

Prior Authorization Request

To submit a prior authorization request, you have a few options. You can submit by direct data entry or by fax.

The agency no longer accepts prior authorization requests or supporting documentation by mail. If you're submitting drugs through the pharmacy point-of-sale (POS) system, a barcode cover sheet is not required. You can submit supporting documentation by fax or direct data entry.

Credit: youtube.com, Submitting Successful Prior Authorizations

If you're submitting supporting documentation to an existing authorization, you'll need to use a specific cover sheet. For general PA requests, use the Pharmacy Information Authorization (HCA 13-835A) form as the first page followed by supporting documentation.

If HCA faxed a specific form for the drug or drug class, fax the form as the first page followed by the supporting documentation.

Guidelines and Process

The prior authorization process can be complex and time-consuming, but understanding the guidelines and process can help streamline it. The EPA number must be used when billing the agency, and upon request, a provider must provide documentation showing how the client's condition meets all the EPA criteria.

A prior authorization process typically begins with the healthcare provider identifying the need for a service or medication that requires prior authorization. This involves determining the patient's need for a procedure, medication, or equipment that requires authorization.

The key steps in the prior authorization process include submission of a request, review by the insurance company, communication of the decision, and treatment or appeal. The insurance company reviews the request, which may involve their own medical experts.

Credit: youtube.com, Understanding Prior Authorization

To minimize prior authorization delays, healthcare providers can find low-priced alternative drugs, prescribe generic drugs, and create a list of processes and drugs that need prior authorization. They can also follow guidelines given by payers while submitting claims.

Here are the key steps in the prior authorization process:

  • Identification of Need: The provider determines the patient's need for a procedure, medication, or equipment that requires authorization.
  • Submission of Request: The healthcare provider or their staff submits the authorization request to the insurance company.
  • Review by Insurance Company: The insurance company reviews the request, which may involve their own medical experts.
  • Communication of Decision: The insurance company communicates their decision to the healthcare provider and the patient.
  • Treatment or Appeal: If approved, the provider proceeds with the treatment. If denied, they may appeal the decision or consider alternate treatments.

Automation and Efficiency

Automating the prior authorization process can significantly reduce the administrative burden on healthcare providers. By automating quality assurance, eligibility verification, and benefits mapping, providers can catch errors early on and prevent delays in patient treatment.

According to the American Medical Association (AMA), physicians spend 16 hours per week on authorizations, which can delay access to care. Automating the prior authorization process can help reduce this administrative burden and give doctors more time to focus on patient care.

Automation can also reduce the need for manual checks on authorization status, freeing up staff to focus on improving approvals and accuracy. With automated responses, including denial numbers, staff work queues, or instructions, providers can streamline their workflow and reduce waiting times.

Credit: youtube.com, Prior Authorization Automation Case Study Webinar with Cleveland Clinic and PriorAuthNow

Here are some benefits of automating the prior authorization process:

  • Speed up the process for obtaining prior authorizations
  • Less administrative and medical work is required
  • Insights into the permission status of real-time data
  • Accelerate the delivery of patient treatment
  • Reduce denials and monitor the frequency of non-payment
  • Improve first submission success to decrease AR backlog and increase cash inflow
  • Increasing income by being fully reimbursed for all services rendered
  • Boost general practice output

By automating the prior authorization process, healthcare providers can improve patient satisfaction, reduce administrative burdens, and increase efficiency. With the right automation tools, providers can streamline their workflow, reduce errors, and focus on providing quality care to their patients.

Health Plan and Insurer Requirements

Health plans and insurers have their own rules when it comes to prior authorization. Medical policies determine what procedures, medication, and equipment are eligible for reimbursement, and these payer rules govern when prior authorization is required on a health plan by health plan basis.

Each health plan has its own rules, so it's essential to review the policy and fee schedules to determine if a code or service requires prior authorization. HCA's authorization services, for example, don't consider National Correct Coding Initiative (NCCI) guidelines when processing a request.

Health insurers require prior authorization to ensure that the services or drugs prescribed are truly needed as per the patient's condition. They check if the recommended drug or service is necessary for the current situation and if it makes financial sense.

Credit: youtube.com, 30 Days of US Healthcare: Prior Authorizations

Payers also check for duplicate services, such as if multiple specialists are involved in treating a single patient. If a particular scan is prescribed by a specialist one week back and the second specialist suggests the same scan, the payer might not authorize the second scan unless the specialist gives a strong need.

Here are some common reasons why health insurers require prior authorization:

  • Is the drug or service required?
  • Is the recommended drug or service necessary for the situation?
  • Does the prescribed drug or service make financial sense?
  • Is there a duplicate service suggested?
  • Is the recurring service benefiting the patient?

It's also worth noting that Medicare, the traditional program offered directly through the federal government, does not usually require prior authorization, even for expensive procedures like surgeries. However, Medicare Advantage plans and Medicare Prescription Drug Plans often require prior authorization, especially for out-of-network care or to see a specialist.

Request Outcomes

A prior authorization request can have three different outcomes: a denial, a redirection, or a withdrawal.

A denial is the most common outcome, where the health plan decides that the requested treatment is not medically necessary.

Credit: youtube.com, Prior Authorization Walkthrough

If the denial is due to incomplete member benefit or clinical information, it's considered an administrative denial.

If the request is denied due to the insurance company's judgment about medical necessity or appropriateness of the treatment, healthcare providers can initiate an appeal process.

The appeal process usually involves providing additional information or documentation supporting the need for the treatment.

If the request is redirected, it means the prescribed treatment is denied from one site of care and redirected to a lower acuity outpatient site of care.

A withdrawal of the prior authorization from the ordering provider can also occur, although this is less common.

Here are the possible outcomes of a prior authorization request:

  1. A denial.
  2. A redirection.
  3. A withdrawal of the prior authorization from the ordering provider.

Automation and Technology

Automation and technology have revolutionized the prior authorization process, making it faster, more efficient, and less prone to errors. With automation, healthcare providers can streamline their workflow and reduce the administrative burden associated with prior authorization.

Automating quality assurance is a crucial step in the prior authorization process. This involves measuring patient data before submitting prior authorization and auditing 100% of patient registrations to detect errors. By doing so, staff can be alerted to detected errors along with recommended solutions, reducing the risk of errors and improving the overall process.

Credit: youtube.com, Automating Medical Necessity for Prior Authorization, Sponsored by MCG Health

Automating eligibility verification and benefits mapping can also help detect errors before they impact the revenue cycle. This can be achieved through Robotic Process Automation (RPA), which can analyze data and identify potential issues. By automating benefit verification on 100% of accounts, healthcare providers can reduce the risk of errors and improve the accuracy of their prior authorization submissions.

The automation of prior authorization can significantly reduce the time spent on the phone and at the fax machine. This is because automation can determine if authorization is required according to payer guidelines, reducing the need for manual checks and phone calls. As a result, staff can dedicate more time to improving approvals and accuracy, rather than simply waiting for updates.

Here are some benefits of automating prior authorization:

  • Speed up the process for obtaining prior authorizations.
  • Less administrative and medical work is required.
  • Insights into the permission status of real-time data.
  • Accelerate the delivery of patient treatment.
  • Reduce denials and monitor the frequency of non-payment.
  • Improve first submission success to decrease AR backlog and increase cash inflow.
  • Increasing income by being fully reimbursed for all services rendered.
  • Boost general practice output.

By automating the prior authorization process, healthcare providers can improve patient satisfaction, increase efficiency, and reduce the administrative burden associated with prior authorization. With automation, healthcare providers can focus on providing quality care, rather than simply managing the prior authorization process.

Frequently Asked Questions

What are the steps involved in a prior authorization process?

To initiate a prior authorization, follow these 5 steps: Check client eligibility, determine if a code or service requires Prior Authorization, find and complete necessary forms, submit a PA request, and track the status of the authorization.

What are 10 procedures that frequently require preauthorization from the insurer before completion?

Here are 10 common medical procedures that often require preauthorization: MRIs, CT scans, PET scans, wheelchairs, at-home oxygen, patient lifts, infusion therapy, inpatient procedures, skilled nursing visits, and home health care services. Preauthorization ensures these procedures are medically necessary and covered by your insurance plan.

Ann Lueilwitz

Ann Lueilwitz

Senior Assigning Editor

Ann Lueilwitz is a seasoned Assigning Editor with a proven track record of delivering high-quality content to various publications. With a keen eye for detail and a passion for storytelling, Ann has honed her skills in assigning and editing articles that captivate and inform readers. Ann's expertise spans a range of categories, including Financial Market Analysis, where she has developed a deep understanding of global economic trends and their impact on markets.

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