What is a prior authorization and when is it typically required?

• A. A pre-certification from the payer before a service to determine coverage; required for many high-cost or specific services.
• B. A post-certification from the payer after a service to determine coverage.
• C. A document sent after claim submission to obtain additional payment.
• D. A patient consent form for medical imaging.

Answer: (A)

Prior authorization is a pre-certification obtained from the payer before a service is performed to confirm coverage and medical necessity. It’s typically required for high-cost procedures, inpatient admissions, certain imaging tests, and other services defined by the payer’s guidelines. The clinician or facility submits clinical justification and supporting documentation, and the payer reviews it to decide whether to approve or deny coverage before the service occurs. This helps ensure the service will be reimbursed and protects the patient from unexpected out-of-pocket costs.

The other concepts don’t fit because authorization occurs before the service, not after. A post-service decision is not the standard prior authorization. A document sent after claim submission to obtain more payment isn’t the authorization itself. A patient consent form for imaging relates to consent for the procedure, not to payer approval of coverage.