Many companies now require Prior Authorization (prior auth) in order to determine whether a claim will be paid. Pacific Source started Prior Auth and after one year decided to stop, the rest of the companies saw what Pacific Source started and decided to join in. The following year, many companies required prior auth. Many plans that require prior auth for some services do not require it for all.
Prior authorization from the insurance company, or in many cases, a third party company (evicore is the most common one) is hired by the insurance company to employ individuals with medical expertise who have access to some of your health information, through your providers reports, to determine whether or not the services recommended by the provider you chose to see will be covered by your plan. Regardless of whether your plan offered coverage for this services in the pamphlet.
Often, your provider uses the online system determined by the insurance company to ask a series of questions regarding your health and their assessment as well as what they are treating, your prognoses, etc. Imaging results, labs, others tests, paragraph style open text from your provider and other details can also be uploaded.
Prior Authorization can be an immediate, electronic decision or a reviewed decision that can take days and up to months for the decision to be made. For acupuncture, chiropractic care, and massage/ physical therapy, prior authorization approvals are in writing and include a number of approved codes of service and number of visits. They expire after 30 days and can be extended one time for a maximum of 30 days. We track these services and codes and then we log in as needed to request additional visits. Once the condition is resolved, the patient is no longer seeking care for a period. Then, as something new perhaps presents itself, we see the patient and learn about that question at an appointment, take that information and log in to determine if we can get prior authorization for the treatment plan we think is needed. This goes on like this for each condition as needed.
If a request for prior auth is not immediately approved it is sent to medical review. This means a team of folks with some medical training are going to review it at the third party company or at the insurance company. For our services this usually takes a few hours or up to a few days. The provider has 7 days from the date of service to request the authorization for most plans, some allow 14.
Prior authorization requirements and medical necessity denials can have rippling effects for individual health insurance subscribers (you), employer based subscribers, the entire healthcare services system (ei; dr’s offices, clinics, pharmacies, and hospitals) and, most importantly, everyone’s health.
Medical necessity review is the process that MODA uses for OHSU plans and is similar to prior auth. For this one, and others like it, a set number of visits is allowed, in this case 25 prior to your provider mailing all your chart notes to MODA. This must occur for a review to determine how many of the remaining 60 visits advertised as part of your plan, are accessible to your. The response typically takes a few weeks, once received, if approved, a specific number of additional visits is listed.