Whose responsibility is to obtain authorization?
Asked by: Prof. Kaitlin Balistreri Jr. | Last update: October 25, 2025Score: 4.5/5 (9 votes)
Who is responsible for obtaining an authorization?
Your doctor's office is responsible for obtaining prior authorization. They will submit a request to your insurance provider to get approval, whether it's for a service or for a medication. Usually, your physician will have a good idea of whether they need to get prior authorization.
Does prior authorization come from doctor or insurance?
Healthcare providers or patients' representatives send Prior Authorization requests to insurance companies. The healthcare provider is usually the best source of information about the requested treatment or medication and can provide the necessary clinical information to support the request.
Who handles submitting a request for a prior authorization for care?
Under prior authorization, the provider or supplier submits the prior authorization request and receives the decision before services are rendered.
Who obtains prior authorization?
Prior authorization—sometimes called preauthorization or precertification—is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.
Understanding Prior Authorization
Who is responsible for authorization?
Authorization is the responsibility of an authority, such as a department manager, within the application domain, but is often delegated to a custodian such as a system administrator.
Whose responsibility is prior authorization?
The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patient's insurance provider. As mentioned in the “How does prior authorization work?” section above, this will then often prompt a time-consuming back and forth between the provider and payer.
Who files prior authorization?
Your health care provider can make the prior authorization request. If your provider submits the request, they will send the required information to your health plan. You may need to fill out forms for your provider's office.
Who do I call for prior authorization?
Assuming you're using a medical provider who participates in your health plan's network, the medical provider's office will make the prior authorization request and work with your insurer to get approval, including handling a possible need to appeal a denial.
What is the new CMS rule on prior authorization?
Beginning primarily in 2026, impacted payers (not including QHP issuers on the FFEs) will be required to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests for medical items and services.
Can insurance deny a prior authorization?
Your physician's team must provide your insurer with all this information – and doing so is time-consuming. An insurance reviewer will look at what treatments or medications are being requested and review the records submitted. The reviewer decides if the insurer will approve or deny the prior authorization.
What are your main responsibilities as a prior authorization specialist?
- Handles the verification of insurance benefits for customers.
- Notifies customers of deductibles and co-insurance due.
- Contacts primary care physicians in regards to referrals.
- Regularly calls insurance companies to follow up.
- Explores other payment options with customer when needed.
How do pre-authorizations work?
During the pre-authorization period, the funds aren't actually transferred to the merchant. Instead, they're set aside in a temporary reserve, and can't be spent by the customer until the pre-authorization hold is released. Once the transaction is completed, the hold is removed and the actual charge is processed.
Can a doctor's office charge for prior authorization?
Medicare does not require referrals or pre-auths. Some Medicare Advantage plans are starting this practice. Per CMS, you are not allowed to charge for any additional fees like pre-auths.
WHO issues authorization?
In a multi-user system, the system administrator uses the authorization mechanism to define permissions for each user or group of users. Once a user is logged in, via a process called authentication, the system determines which resources should be available to them during their session.
What happens if the authorization is denied?
If your request for prior authorization is denied, then you and your patient will be notified about the denial. The first step is to understand the reason behind the denial, so contact the health insurance company to find out the problem. For example, a PA request for a medication might be rejected due to many reasons.
Who initiates the prior authorization request?
If your health care provider is in-network, they will start the prior authorization process. If you don't use a health care provider in your plan's network, then you are responsible for obtaining the prior authorization.
Why is it so hard to get a prior authorization?
Insurance companies can deny a request for prior approval for reasons such as: The doctor or pharmacist didn't complete the necessary steps. Filling the wrong paperwork or missing information such as service code or date of birth. The physician's office neglected to contact the insurance company due to a lack of time.
Who works on prior authorizations?
Most healthcare providers do not have jobs dedicated to prior authorization. Instead, you submit requests as a member of the office or clerical staff as part of your duties. Insurance companies do have dedicated positions, particularly for reviewing unusual cases and deciding whether or not to authorize them.
Who is allowed to receive patient records without authorization?
When Can PHI Be Released without Authorization? The major exception to the need for specific authorization for the release of PHI is that medical care providers may release information to other providers and entities who are participating in the patient's care, and to business that provide services for those providers.
Can you bill a patient if a claim was denied for no authorization?
If you fail to go through preapproval as outlined in your contract and then the payer denies the claim, you can't pass the costs on to the patient, since you missed a step in the billing process.
Can medical assistants do prior authorizations?
Medical Assistant: The medical assistant's role in this process is to assist the prescriber in filling out and submitting the PA form. This can include verifying information with the pharmacy and obtaining all required documentation from the patient's health record, as mentioned above.
How can I speed up my prior authorization?
- Create a master list of procedures that require authorizations.
- Document denial reasons.
- Sign up for payor newsletters.
- Stay informed of changing industry standards.
- Designate prior authorization responsibilities to the same staff member(s).
What is the policy of prior authorization?
Prior authorization in health care is a requirement that a healthcare provider (such as your primary care physician or a hospital) gets approval from your insurance plan before prescribing you medication or doing a medical procedure.
Who is required to obtain a prior authorization for a service or procedure quizlet?
patient's insurance payer. Prior authorization for procedure or services is required by insurance payers to verify medical necessity, policy coverage and must be obtained before a procedure is performed.