In the context of billing and claims processing, what is prior authorization?
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Medical Office Assistant · Medical Economics, Billing, and Coding
Prior Authorization and Referrals
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Which of the following terms is generally used interchangeably with 'prior authorization'?
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What is the primary purpose of requiring prior authorization from a payer?
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What is a predetermination of benefits?
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A payer approves an authorization but states that the service must be performed within a certain number of visits or days. What is this limit called?
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Study tools & related lessonsYou’ll learn to · Related
You’ll learn to
- Describe prior authorization and referral processes and distinguish them from one another.
- Explain the documentation, codes, and information required to support authorization and referral requests.
- Demonstrate timely submission, tracking, renewal, and follow-up practices that keep authorizations valid.
- Recognize common denial causes and apply front-end practices that prevent authorization- and referral-related denials.
- Apply scope-of-practice boundaries by coordinating information and escalating clinical and coverage decisions to clinicians and billing staff.
Sources & references
- Centers for Medicare & Medicaid Services — CMS.gov
- American Health Information Management Association — AHIMA - Health Information and Coding
- AAPC — Medical Coding and Billing
This lesson was adapted from the open educational references above; their licenses and attributions are preserved. See Copyright & Licensing.
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