Introduction
Insurance prior authorization (often referred to as a "prior auth" or "pre-authorization") is a process in which a healthcare provider must obtain approval from a patient’s health insurance company before certain medical services or medical equipment and supplies are provided. This approval is required to ensure that the service or product is covered under the patient's insurance plan, and to determine that the service is medically necessary.
Key Points about Prior Authorizations:
Pre-Approval Process: Insurance companies require healthcare providers to submit documentation supporting the medical necessity of a product or service before it is provided to the patient. The insurance company reviews this information and decides whether they will authorize the service or product.
Required for Certain Services: Not all medical services or products require prior authorization. It is typically required for specific products or services based on payer guidelines.
Best Practices for Managing Prior Authorizations in NikoHealth:
Stay Organized: Use NikoHealth’s tools for authorization workflow and task management to track pending or expiring prior authorization requests.
Timely Follow-ups: To manage timely follow-ups on pending and expiring authorizations, it's important to stay organized and proactive. Look for authorizations that are still awaiting approval. These would be in a ” pending” status. Filter the queue by expiration dates to identify authorizations that are near their expiration (e.g., within 5-7 days). This will help you focus on those requiring immediate action.
Create Payer Authorization Rules: Creating Payer Authorization Rules is an essential step in automating the prior authorization process for commonly submitted services, HCPCS (Healthcare Common Procedure Coding System) codes, or products. By defining specific rules for when prior authorization is required, administrators can streamline the workflow, reduce errors, and improve overall efficiency in managing insurance claims.
Learn More
By effectively managing prior authorizations within NikoHealth, you can streamline the process, reduce administrative burden, and improve patient care by ensuring that products and services are pre-approved in a timely manner. Be sure to familiarize yourself with NikoHealth’s specific features for managing prior auths, and use its automation tools to save time and avoid errors. Check out the articles below: