Prior Authorization definition

Prior Authorization means a decision by AvMed, prior to the time a Health Care Service or other benefit is to be delivered, that the Health Care Services are Medically Necessary. Prior Authorization is sometimes called pre-authorization, prior approval or pre-certification. AvMed requires you or your Physician to obtain Prior Authorization for certain services and medications before you receive them to ensure that you receive the most appropriate treatment. Prior Authorization is not a promise that AvMed will cover the cost of such services or medications.
Prior Authorization means approval for the provision of a service or the delivery of goods from the department before the provider actually provides the service or delivers the goods;

Examples of Prior Authorization in a sentence

Emergency Service care does not require any Prior Authorization from the Plan.

The health care professional, however, may be required to comply with certain procedures, including obtaining Prior Authorization for certain services, following a pre-approved Treatment Plan, or procedures for making referrals.

Unlisted Codes That Do Not Require Prior Authorization or Additional Supporting DocumentationFor a limited group of unlisted procedure codes, ForwardHealth has established specific policies for their use and associated reimbursement.

Please see Prior authorization in Referrals and Prior Authorization for more information about prior authorization requirements and processes.

Prior Authorization and Review Procedures:Contractor shall ensure that its pre-authorization, concurrent review and retrospective review procedures meet the following minimum requirements…(as required by Contract)2-Plan Contract A.5.2.A, B, D, F, H, and I.


More Definitions of Prior Authorization

Prior Authorization means Molina’s prior determination for Medical Necessity of Covered Services before services are provided. Prior Authorization is not a guarantee of payment for services. Payment is made based upon the following; benefit limitations exclusions Member eligibility at the time the services are provided and other applicable standards during the claim review.
Prior Authorization means VIVA HEALTH has given approval in advance for payment for certain Covered Services to be performed. Prior Authorization may include place of service. Authorization does not guarantee payment. For information on services requiring Prior Authorization, see Part VIII.D of this Certificate.
Prior Authorization or “Prior Authorized” means a system that requires a Provider to get approval from HPN before providing non-emergency healthcare services to a Member for those services to be considered Covered Services. Prior Authorization is not an agreement to pay for a service.
Prior Authorization as it relates to the PDL, means the process of review by a clinical pharmacist of legend drugs that are not on the preferred drug list, or other drugs as recommended by the Pharmacy and Therapeutics Committee, to determine if medically justified.
Prior Authorization means Molina’s prior determination for Medical Necessity of Covered Services before services are provided for a Member.