How do medical front office check to see if patient health insurance requires prior authorization for service? If it does require, how do they initiate the prior authorization process?
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when you get health insurance, you are assigned a member number (that identifies you) and a group number (that identifies the specific contract your company has negotiated with the provider). they enter the group number in the company’s website, look up the procedure or visit type you’re there for, and see what it says about any requirements: is pre-auth required? is there a co-pay (fixed amount you pay for the visit)? is it partially or wholly covered and at what rate? etc. if pre-auth is required, then there is a way to request it or see if you have it already. it’s been a while, but i think your primary doc (or their office) has to contact the insurer and say “i want my patient to have this procedure or see this specialist. please approve” and hopefully they will approve. it’s not a fast process, so if the auth isn’t there, you’re either paying for the visit yourself or not having it that day.
most doctors offices have a person whose job it is to a) submit the request such that it gets approved, and b) submit the request for payment such that the doc gets the most amount of money from the insurance. because “itch on arm” may be worth $10, but “potential allergic reaction to environmental factors” is worth $200 but both present as an itch on the arm, but the insurers have arcane rules about things
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