Tips from Paula: Prior Authorization for Services

Here at Acadia Benefits, we are proponents of ongoing education for our customers and their employees.  One area that seems to come up frequently is the process of obtaining authorization for certain services.

Your doctor may order a test, such as an MRI, PET scan, or CT scan.  These are considered “high-level imaging” and most carriers require prior authorization for these tests.  This means the ordering physician is required to call the carrier or the carrier’s third-party authorization company, to provide medical necessity and background, in order to obtain approval.  The specific benefits subject to the prior authorization may vary depending on your carrier, plan, or product.

Depending on the diagnosis of the patient, the carrier may request that they first try physical therapy, pain medication, or other modalities, before they will approve some tests.  The same applies to upcoming surgeries.  The provider must call the carrier to obtain authorization, again, explaining the diagnosis, procedure to be performed, and the patient’s medical background.  Once all of this is provided, and the surgery or test is considered medically necessary, approval should be granted.

It is ultimately the responsibility of the patient to ensure prior authorization has been granted for surgeries or tests.  We suggest referencing the appropriate member materials (ie; benefit handbook), or call member services at your carrier, using the contact information found on their ID card.  And I am always available to help!  Just let your employees know they can contact me at any time, via email or phone, and I am happy to intervene if need be.



Paula Green