Is an authorization even required?

3 min read

Before any of the rest of this matters, somebody has to answer a deceptively simple question: does this service, for this patient, under this plan, need prior authorization? Get it wrong in one direction and you delay care and burn staff time on an unnecessary request. Get it wrong in the other and the claim denies after the service was already delivered.

#What the answer actually depends on

The specific plan, not the insurer. Requirements vary between products from the same carrier.
The procedure code, often down to the specific CPT or HCPCS code rather than the category.
The place of service. The same procedure can require authorization in an ambulatory surgical centre and not in an office, or the reverse.
Sometimes the diagnosis, where a payer requires authorization only outside a defined indication.
Sometimes the provider. Gold carded providers may be exempt for specific services.
The date. Payer requirement lists change, commonly quarterly, sometimes with little notice.

The three bad answers

Answering from memory means answering from a requirement list that may have changed. Answering from a spreadsheet means answering from whenever somebody last updated it. Answering by submitting everything means paying the administrative cost of authorizations you never needed, and training your staff to treat the process as noise.

#Better sources, in order of reliability

The payer's eligibility response: Some payers return authorization requirement information in the 271. Where available this is the most current answer, because it comes from the plan at the time you asked. Coverage varies widely and it is rarely complete enough to be the only source.
The payer's published prior authorization list: Most payers publish a code list, often as a PDF or a lookup tool, with an effective date. This is authoritative but it is a document, which means somebody has to notice when it changes.
The payer's own lookup tool: Many payers offer a code lookup in their provider portal. Current, but per-payer and manual.
A call to the plan: Slow, but definitive, and the reference number from the call is worth recording.

#The rule that is easy to miss

An authorization requirement attaches to the plan, and a patient's plan can change mid-year. A patient who did not need authorization for a surveillance colonoscopy in March may need one in July because their employer changed carriers in between. Practices that check requirements at scheduling and then act months later at the service date are checking against a coverage state that may no longer exist.

This is a strong argument for re-verifying eligibility close to the service date as well as at scheduling, and for treating a coverage change as an event that should re-open the authorization question rather than something noticed at billing.

#What good looks like

Ask at scheduling
Run eligibility when the procedure is booked, not when it is imminent. This is where lead time comes from, and lead time is the only defence against a payer that takes its full decision window.
Record the answer with its source
Not just "auth required: yes", but where that came from and when. When a claim denies eight months later, the source is what lets you argue.
Re-check on any coverage change
A new plan is a new requirement list. Treat it as a trigger, not a footnote.
Re-verify before the service date
Cheap, and it catches the coverage that lapsed between booking and procedure.

A note on self-pay

A patient who is genuinely self-pay needs no authorization, and running the process for them wastes everyone's time. But "the patient said they are self-pay" and "the patient has no coverage" are different statements. Verify rather than accept, because a patient who forgot they have secondary coverage becomes a billing problem later.