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Prior Authorization

Author: Zaibunnisa Begum

Prior Authorization is a process of cost control in a health plan, where the physicians or any other health care providers are required to

obtain approval in advance from the registered insurance company before delivering any specific service to the patient for medical payment coverage.

Prior Authorization is also sometimes called as Pre-Certification and

Pre- Approval. The main concept of the prior authorization process is to make sure that an individual receives access to all medical services required and for which he/she is eligible for.

When an individual holding an active health plan undergoes any services or treatment then the health care providers before delivering the services, approach the health plan and take the pre-approval or prior authorization for payment coverage so that there will be a smooth flow of billing.

Prior Authorization is mandatory in case of critical treatments to avoid any further coverage issues. It reduces the waiting time of a patient before the start of treatment. It also manages the possibility of overprescribing, and also enables hassle-free claims for all the bills.

Process of Authorization:

There is a structured process for Prior Authorization, given by insurance companies from the United States of America.

• The eligibility of the client/ patient is checked.
• Determination of the requirement of prior authorization is done.
• All the required forms are collected and filled.
• Submission of Prior Authorization request is done.
• Status of Authorization is checked in a timely on respective portals.

Types of authorizations:

• Electronic Authorization: In this case, the authorization process is done using a specific software digitally, whereas in manual input is not much required.
• Manual Authorization: Here the process of authorization is done manually, where all the forms are checked and all the bills and claims are manually calculated.

How it is beneficial for an individual?

Every individual who has an active health plan and undergoes prior authorization has different benefits like,

• Treatment can be started without any formalities which will not delay the process of treatment.
• Cost of expensive treatment can be reduced.

Is it mandatory to have medical insurance?

In the current era, looking into the high demand of medical treatments and medication and the growth of charges, it is a must for every individual to hold an active insurance plan which covers all the medical services and also covers all the uncertain situations which takes place all of the sudden.

In foreign countries like USA, it is mandatory for every individual to have a medical insurance. In India, there is no such rule that it is mandatory to hold an active insurance plan but to avoid all the uncertain situations and for hassle-free treatment and medical services it is a must to have a medical insurance policy. An individual can reduce the billing cost, and avoid all the overprescribing from commercial hospitals as the bills are to be sent for claims.

Keywords:

Cost Control | Medical Payment Coverage | Pre-Certification | Pre- Approval | Critical Treatments | Eligibility | Requirement | Status of Authorization | Expensive | Active Insurance Plan | Medical Services | Uncertain Situations | Over-Prescribing | Billing Cost

References:

https://www.cigna.com/

https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.canarahsbclife.com%2Fblog%2Fhealth-plan%2Fwhy-must-you-buy-a-health-insurance-during-covid-19-pandemic.html&psig=AOvVaw2gDMUex-3vv2_vwIgjeA7L&ust=1672131431781000&source=images&cd=vfe&ved=0CBAQjRxqFwoTCMDc1qL1lvwCFQAAAAAdAAAAABAE

https://www.google.com/url?sa=i&url=https%3A%2F%2Flegionhp.com%2Fprior-authorization-services%2F&psig=AOvVaw3ZPDP9PdM2FuZWEv9Now1N&ust=1672130110197000&source=images&cd=vfe&ved=0CBAQjRxqFwoTCOCN2cb2lvwCFQAAAAAdAAAAABAD

https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.rivethealth.com%2Fblog%2Fimpact-of-prior-authorization-process&psig=AOvVaw2zWDs-3M9wR5W2AKPT7Y9e&ust=1672129178473000&source=images&cd=vfe&ved=0CBAQjRxqFwoTCLiRxtL2lvwCFQAAAAAdAAAAABAE

https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.viaante.com%2F2019%2F02%2F12%2Fall-you-need-to-know-about-prior-authorizations%2F&psig=AOvVaw2zWDs-3M9wR5W2AKPT7Y9e&ust=1672129178473000&source=images&cd=vfe&ved=0CBAQjRxqFwoTCLiRxtL2lvwCFQAAAAAdAAAAABAK

Source:

• Google.com
• Inside the Insurance Industry – Kevin Glaser
• Live Your Life Insurance – Kim D. H. Butler

I, Zaibunnisa Begum, student of B. Pharmacy (IV – I SEM) from Princeton College of Pharmacy declare that the above article is originally written by me and is accurate.

Date: 26/12/2022
Signature: Zaibunnisa