A prior authorization request is a formal process where a healthcare provider seeks approval from a payer, such as an insurance company, before proceeding with specific medical services, procedures, or medications. This request ensures that the proposed treatment or service is covered under the patient’s health plan and meets clinical guidelines. The provider submits relevant clinical information to justify the need for the service. The payer reviews the request to determine if it aligns with coverage criteria and medical necessity. Approval is required to authorize payment and proceed with the treatment, helping manage costs and ensure appropriate care.

Who Makes the Requests

Under the CMS Interoperability and Prior Authorization Final Rule, it is primarily the healthcare provider who is required to submit the prior authorization request data. This means that:

• Providers (e.g., physicians, nurse practitioners, or other healthcare professionals) are responsible for gathering and submitting the necessary information to the payer to initiate the prior authorization process.

In some cases, providers’ administrative staff or billing departments may handle the submission of prior authorization requests on behalf of the healthcare provider.

What Services Are in Scope for Prior Authorization Requests

Under the CMS Interoperability and Prior Authorization Final Rule, the scope of services requiring prior authorization can include a variety of items and services. Generally, these can encompass:

1. Medical Services
   • Surgical procedures
   • Diagnostic tests and imaging (e.g., MRI, CT scans)
   • Specialty consultations
2. Pharmaceuticals
   • High-cost medications or specialty drugs
   • Certain prescription drugs that require prior authorization due to cost or specific criteria
3. Durable Medical Equipment (DME)
   • Wheelchairs
   • Prosthetics and orthotics
   • Home medical equipment
4. Home Health Services
   • Home health care
   • Hospice care
5. Inpatient and Outpatient Services
   • Hospital admissions
   • Certain outpatient procedures or therapies
6. Behavioral Health Services
   • Mental health and substance use disorder treatments

The specific services and items that require prior authorization can vary by payer and plan. Payers are required to make their prior authorization requirements clear, including which services or items are subject to prior authorization and the criteria for approval. Providers should check with individual payers to understand their specific requirements and ensure they submit prior authorization requests for the appropriate services.

How & What Data is Required to Make a Request for Prior Authorization

There are specific requirements for how providers must submit the required data for prior authorization requests.

How Data Prior Authorization Request Data Must Be Provided by Healthcare Provider

The CMS Interoperability and Prior Authorization Final Rule outlines several key requirements:

1. Electronic Submission
   • Providers are encouraged and often required to use electronic methods for submitting prior authorization requests and responses. This includes using standardized formats such as the Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR) standards and Application Programming Interfaces (APIs).
2. Standardized Data Formats
   • The data must be provided in standardized formats to ensure consistency and interoperability between different systems. This often involves using standard codes and formats for clinical information (e.g., CPT codes, ICD codes).
3. Machine-Readable Format
   • Providers must ensure that the information is in a machine-readable format, which means it can be easily processed by electronic systems used by the payer.
4. Complete and Accurate Information
   • The request must include all required data elements, such as patient information, provider details, service/item descriptions, and supporting clinical documentation. Incomplete or inaccurate submissions can lead to delays or denials.
5. Timely Submission
   • Requests should be submitted as soon as possible to avoid delays in patient care. Payers may have specific guidelines for submission timelines.
6. Compliance with HIPAA
   • Providers must ensure that the submission of data complies with HIPAA regulations, safeguarding patient privacy and data security.
7. Clear Documentation
   • The clinical justification and supporting documents must be clear and relevant to the request, ensuring that payers have all necessary information to make a decision.

By adhering to these requirements, providers can help ensure a smooth and efficient prior authorization process.

What Prior Authorization Request Data Must Be Provided by Healthcare Provider

Payers are required to make it easier for providers to submit these requests by implementing electronic systems and standardized formats, ensuring that the process is efficient and accessible. For prior authorization requests and responses, the CMS Interoperability and Prior Authorization Final Rule specifies that certain data elements must be included to ensure clarity and completeness. Here’s a general overview of what should be included:

1. Patient Information
   • Patient’s name
   • Date of birth
   • Patient ID or medical record number
   • Contact information
2. Provider Information
   • Provider’s name
   • National Provider Identifier (NPI)
   • Contact information
3. Service or Item Information
   • Description of the service or item being requested
   • CPT/HCPCS codes or other relevant codes
   • Quantity, duration, or frequency of the requested service or item
4. Clinical Information
   • Relevant clinical notes or documentation
   • Diagnosis codes (ICD-10)
   • Justification or rationale for the requested service or item
5. Supporting Documentation: Any additional documents required for the request (e.g., lab results, imaging reports)
6. Requested Dates: Dates for which the service or item is being requested

By When Must the Provider Request a Prior Authorization

The timeframe for submitting a prior authorization request can vary depending on the payer and the specific type of service or item being requested.

Typically, providers should follow these guidelines:

1. Follow Payer-Specific Timelines: Providers should check the payer’s specific requirements for submitting prior authorization requests, as some payers may have their own deadlines or preferred timeframes.
2. Adhere to Clinical Guidelines: For urgent or time-sensitive services, such as emergency care, providers should submit prior authorization requests as quickly as possible to ensure timely care for the patient.
3. Check Contractual Agreements: Providers should also be aware of any contractual agreements or terms outlined in their contracts with payers, which may specify timeframes for prior authorization requests.

Overall, it’s important for providers to submit requests as soon as they are able to ensure that the prior authorization process does not delay patient care.

Payer Definition

A payer is an entity responsible for covering or reimbursing the cost of healthcare services and products. In the context of healthcare, payers typically include:

1. Health Insurance Companies: These are private companies that provide health insurance plans and are responsible for paying claims related to covered medical services and treatments.
2. Government Programs: Public programs such as Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) act as payers by providing health coverage and funding for eligible individuals.
3. Employers: Some employers directly provide health benefits to employees through self-funded health plans, acting as payers for the medical services their employees receive.
4. Third-Party Administrators (TPAs): These organizations manage health insurance claims and administrative services on behalf of employers or insurers, but they do not assume financial risk themselves.