Also called pre-authorization or pre-certification, it lets a payer check a request against its coverage criteria before care is given. A request usually needs the diagnosis and procedure codes (ICD-10 and CPT), supporting clinical documentation and the payer's own form or portal submission.
Most of the staff time goes to gathering documentation, matching it to each payer's criteria and answering follow-up questions, rather than to the clinical decision itself. CMS's Interoperability and Prior Authorization final rule (CMS-0057-F) requires impacted payers, including Medicare Advantage and Medicaid plans, to decide within 72 hours for expedited requests and seven calendar days for standard ones from 2026, and to support electronic prior authorization through APIs from 2027.
General information, not legal or tax advice.