Prior Authorization
Payer requirement for approval before a service or device is covered.
Definition
Prior authorization (PA) is a payer process requiring providers to obtain approval - based on medical necessity criteria - before a service, procedure, or device is covered. Common for high-cost devices, advanced imaging, and many DTx/RPM services.What this means in practice
PA is a major friction point for new technology adoption; clinical pathway and PA support tools are increasingly part of the manufacturer commercial model.- •Underestimating PA denial rates and appeal timelines when modeling commercial uptake.
Related terms
Grouped by themeReimbursement & Market Access
· From this learning pathSystematic evaluation of clinical and economic value of a health technology.
CMS pathway providing time-limited Medicare coverage for FDA-designated Breakthrough Devices.
Financial model that estimates the total cost consequences of adopting a new technology to a payer's budget over a defined horizon.
AMA-maintained codes that describe medical procedures and services.
More in Reimbursement
· Same categoryAMA-maintained codes used to report medical procedures and services for billing.
CMS-maintained codes for products, supplies, and services not in CPT.
Diagnosis (CM) and inpatient procedure (PCS) coding systems used in U.S. claims.
Local and National Coverage Determinations from Medicare.
Primary references
3 sourcesInline markers like [1] jump to the matching reference above.