See prior approval.
To be sure certain drugs are used correctly and only when truly necessary, plans may require a “prior authorization.” This means you will need a prior approval from your plan before a particular drug will be covered. In many instances, your doctor or health care provider must first contact the plan and show there is a medically-necessary reason why you must use that particular drug for it to be covered.
Also called Pre-certification or Pre-authorization Prior review of a proposed service using established criteria to determine the appropriateness of care.
Medicare will authorize the payment on certain items based on a completed CMN and medical necessity.
An approval process required for certain drugs. Before these drugs are covered, your doctor will need to contact Express Scripts to see if your plan's conditions for coverage are met. To be approved, your doctor must provide medical evidence that a formulary drug has failed to be an effective treatment for you, or that you have experienced adverse effects from the formulary drug or that changing therapy to a covered medication would be medically inappropriate. Drugs requiring prior authorization are clearly indicated on the Express Scripts website. If the drug is approved for your condition, you'll pay the applicable copayment. If the drug isn't approved for your condition and you still want to take it, you must pay the full cost.
The health plan’s approval that a requested hospital admission, treatment or procedure is a covered service and is medically necessary and appropriate. Also known as pre- authorization or prior approval
A formal process requiring a provider obtain approval to provide particular services or procedures before they are done. This is usually required for nonemergency services that are expensive or likely to be abused or overused. A managed care organization will identify those services and procedures that require prior authorization, without which the provider may not be compensated.
The process by which the Department will advance whether a covered service that requires prior approval will be reimbursed based upon the accuracy of the information received and substantiated through concurrent and/or retrospective medical review.
certain services may require health plan authorization before service is rendered. This authorization does not guarantee payment.
a process of reviewing medical, surgical, and behavioral health services to ensure medical or psychological necessity and appropriateness of care prior to services being rendered
a requirement that a physician must obtain prior approval from the plan for a medication to be paid for by the plan.
In the context of a pharmacy benefit management (PBM) plan, a program that requires physicians to obtain certification of medical necessity prior to drug dispensing. Also known as a medical-necessity review.
The process of obtaining approval from the health plan for a particular health care service before the service is delivered.
A process confirming that a specific treatment or diagnosis will be reimbursed by the insurer prior to treatment. This is also known as preauthorization or precertification.
The process of obtaining advanced approval of coverage for a health care service or medication. Also called Pre-Authorization.
Approval in advance for certain prescription drugs. If prior authorization is not received, Medi-CareFirst Rx may not pay for your drug.
A requirement that a beneficiary receive approval from a health insurer or drug plan in advance of receiving certain medical items or services. Part D drug plans may use prior authorization requirements as part of their drug utilization management programs.
A health care planâ€™s requirement that a plan member or the doctor in charge of the case notify the plan, in advance, of a course of care, such as a hospital admission or expensive diagnostic test.
A process involving review and approval by a health care plan administrator in advance of a recommended treatment plan, procedure or prescription medication. Among considerations for coverage approval by a plan administrator are the plan of benefits, the medical necessity of the recommended therapy and the enrolleeâ€™s health status. Also referred to as prior approval, preauthorization or precertification.
A utilization management strategy that requires a provider to justify, in advance to a third-party utilization reviewer, the need for a particular treatment in order to be reimbursed for that treatment. Also called precertification, preauthorization, predetermination.
The approval a provider must obtain from an insurer or other entity before furnishing certain health services, particularly inpatient hospital care, in order for the service to be covered under the plan.
The process of obtaining approval from a health insurance company prior to receiving a particular health care service.
A referral that is usually obtained through your primary care physician PRIOR to receiving services.
Obtaining prior approval as to the appropriateness of a certain service or medication.
Prior approval necessary for specified services to be delivered for an eligible client by a specified provider before services can be performed, billed, and payment made. A utilization review method used to control certain services which are limited in amount, duration, or scope.
An authorization that has been obtained previously, either through operator or through credit card equipment.
Approval in advance to get services. Some in-network services are covered only if your doctor or other plan provider gets "prior authorization" from a participating medical group, IPA or Secure Health. Covered services that need prior authorization are marked in the Benefits Chart. Prior authorization is not required for out-of-network services. You do not need prior authorization to obtain out-of-network services. However, you may want to check with your plan before obtaining services out-of-network to confirm that the service is covered by your plan and what your cost share responsibility is.
In health insurance, a cost containment measure that provides full payment of health benefits only when the hospitalization or medical treatment has been approved in advance.
An insurance plan requirement that the insured or the provider notify the insurance company prior to certain medical procedures in order for such procedures to be covered under the plan. Prior authorization does not necessarily guarantee coverage.
Makes the pharmacist or doctor get consent from the plan before a prescription can be filled.
The system whereby a Provider must receive approval from the Plan before the Member can receive coverage for certain healthcare services.
A requirement imposed by a utilization review system that, in order to be reimbursed for a treatment, the provider must justify the need for this particular treatment to a utilization review clinician before delivering it (also called pre-authorization, precertification, and predetermination).
Procedures, tests, services, or medications which must be approved in advance by the doctor, utilization management and/or the insurer in order to be eligible for payment from the health plan or insurer.
The requirement of some health care plans that an insured obtain the plan's approval for certain services before the service can be received and paid for by the company.
A process intended to require that pre-defined criteria are met before coverage is authorized for a specific drug or medical procedure.
Procedure used to control utilization of services by prospective reviewing and approval.
Requirement of a third party, under some systems of utilization review, that a provider justify the need for delivering a particular service to a patient before providing service in order to receive reimbursement.
An authorization usually done before a transaction takes place. The approved authorization request may be held for an extended length of time before a card is present or not.
The process associated with specified drug products on the formulary that require additional evaluation by clinical staff prior to coverage being granted.
Approval required in advance of providing particular services to a beneficiary.
A program that requires physicians or other healthcare professionals to obtain certification of medical necessity prior to the dispensing of drugs or ordered services (such as physical therapy). Requirement may be necessary to keep patient within the parameters of the health plan they are covered by.
Certain treatments require prior authorization from Community Health Plan before they are covered; for instance, prior authorization is necessary before you receive treatment from specialists or follow-up treatment when you are out of state.
utilization control that requires you to have a drug plan's permission to use a certain drug.
Specific drugs on a formulary may require that the physician seek approval from the prescription drug plan (PDP) before the prescription can be filled.
Prior approval from an insurance plan before you get care or fill a prescription. In many instances, your doctor or health care provider must first contact the plan and show there is a medically-necessary reason why you must use that particular drug for it to be covered.
A pre-transaction authorization. The approved authorization request may be held for an extended period of time before a card is present or not.
Any requirement imposed by a health benefit plan or its agent for prior review and approval of the medical necessity of a service covered under a health benefit plan, as a condition of plan payment for that service.