Prior Authorization Review definition

Prior Authorization Review also referred to as “precertification” or “prior approval” is a process by which Physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.

Examples of Prior Authorization Review in a sentence

• The following settings, services, treatments, supplies, devices, or prescription drugs require Prior Authorization Review: ▪ Inpatient admissions (including acute care, long term acute care- behavioral health and/or Substance Abuse rehabilitation, residential treatment and partial hospitalization; skilled nursing facility).

• You can obtain Prior Authorization Review by contacting us at: Company: Seton Health Plan, dba: Dell Children’s Health Plan Address: 0000 Xxxxxxxxx Xx., Suite #305 Austin, TX 78723 Phone: 0-000-000-0000 (TTY: 000-000-0000) Fax: 000-000-0000 Email: XXX-Xxxxxxxxxxxxx@xxxxxxxxx.xxx Prior authorization is not a guarantee that benefits will be payable.

• You are responsible for obtaining Prior Authorization Review when required.

• If a setting, service, treatment, supply, device, or prescription drug is listed below, Prior Authorization Review must be obtained before incurring any claims for that setting, service, treatment, supply, device, or prescription drug.

• Benefits due to Insureds are subject to the following Utilization Management: Prior Authorization Review is intended to confirm the Medical Necessity and medical appropriateness of a setting, service, treatment, supply, device, or prescription drug.