Importance of Pre-Authorization in Medical Billing and Claim Submission

Prior Authorization is a term used actively by medical insurance companies. It means that a patient needs to seek permission from the medical insurance provider before undergoing specific medical procedure to claim reimbursement of the bills, except during emergencies.

Although, the approval for Prior Authorization by the insurance company depends on various factors like a medical necessity, appropriateness and the insurance limit. If you did not ask for Prior Authorization, or if your insurer denied to give you Prior Authorization, there will be no reimbursement. On the contrary, even an approved Prior Authorization, does not guarantee that your insurance provider will refund you.

What medications/procedures need Prior Authorization or approval?

Typically, an insurance company ask to seek a Prior Authorization in cases where:

• There is a possibility of a low-cost treatment alternative.
• If the treatment is not suitable for the patient depending on their previous health conditions.
• If the procedure is for a cosmetic or aesthetic purpose than treatment.

What is the significance of Prior Authorization in claim acceptance?

Prior Authorization plays an essential role to maintain revenue management cycle.

Insurance companies work together with dentists to ascertain proper financial management. Although sometimes the insurance companies find ambiguity in bills and to avoid paying anything extra out of their pocket they ask for Prior Authorization. Thus, the dentist and the patient may end up getting no insurance benefit and may end up paying from their pockets.

Sometimes, despite getting Prior Authorization, claims get denied. Therefore, it is essential to understand the significance of Prior Authorization in claim acceptance. To get your claim processed, you must follow the specific steps, which include:

• • Submitting a claim do include the unique Prior Authorization Number:

While submitting a claim, please ensure to include the unique Prior Authorization Number. If you do not include the Prior Authorization Number, there will thus be more possibilities that your application gets denied. Mentioning your Prior Authorization Number decreases the chances of denial of the claim and saves both your time and money simultaneously.

• • Get your Authorization Number before the treatment:

We know that getting a Prior Authorization Number before the treatment can be a very long process on its own. But getting the Authorization number is necessary too. Especially if the procedure is expensive and you do not wish to spend from your pocket. However, during an emergency, the insurer may be a bit flexible and reimburse the bills. But for non-emergency cases, you need to get an Authorization Number before the procedure.

• • If only a part of treatment got Prior Authorization:

Sometimes, patients claim for reimbursement with their unique Authorization Number, but still, their claim gets denied. Have you ever wondered why? Mostly in such cases, the patients get approval for just one part of their overall treatment. So, to avail insurance claim, the approval must be for the entire claim and not partly.

Despite working diligently on many occasions, the claim gets denied. Around 80% of claims that get denied because they do not have a proper authorization number. To get your medical insurance claim sanctioned, please ensure that you get the Prior Authorization Number before the treatment. Overall, the Prior Authorization has a significant role in the smooth processing of your insurance claim.