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GLOSSARY - HEALTHCARE

What is Prior Authorization?

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Quick Answer

Prior Authorization (PA) is the process of obtaining approval from a health insurance payer before delivering specific medical services, procedures, or medications. AI-powered PA automation evaluates clinical documentation against payer criteria to determine medical necessity and expedite approval decisions.

Definition

**Prior Authorization** is a utilization management tool that ensures proposed treatments are medically necessary and covered under the patient's plan. AI automates the evaluation of clinical evidence, policy criteria matching, and documentation completeness checking—reducing processing time from days to minutes.

Key Points

  • Evaluates medical necessity against payer-specific criteria
  • Matches clinical documentation to coverage requirements
  • Identifies missing documentation before submission
  • Reduces PA processing time by 60%
  • Improves first-pass approval rates by 35%
  • Provides appeal-ready documentation for denials

How It Works

1

Request Intake

Clinical documentation and authorization request received

2

Criteria Matching

AI matches clinical indicators to payer medical necessity criteria

3

Gap Analysis

Identifies missing documentation needed to strengthen case

4

Decision Support

Generates recommendation with supporting evidence and citations

5

Submission Package

Creates complete authorization request with medical necessity rationale

Frequently Asked Questions

What percentage of prior authorizations get approved?

Industry average is 65-75% first-pass approval. AI-assisted PA improves this to 80-85% by identifying documentation gaps and strengthening medical necessity arguments before submission.

How long does AI prior authorization take?

AI evaluates authorization requests in minutes versus hours or days for manual review. The bottleneck becomes payer processing time, not internal review.

Can AI handle peer-to-peer reviews?

AI generates talking points, clinical rationale, and relevant literature citations to prepare clinicians for peer-to-peer discussions with payer medical directors.