PRIOR-AUTH
Is Prior Auth Required?
Walkthrough for determining prior authorization requirements by payer, service type, and place of service. Includes common exceptions.
Start
A patient needs a service. Is prior auth required?
Skipping a required PA is the fastest path to a CO-197 denial. Confirm before scheduling, not after.
Decision
If this Medicare or commercial?
Medicare and commercial payers follow different PA rule structures.
Decision
If the CPT in the payer's PA matrix for this plan?
Most commercial payers publish a PA matrix by plan and CPT. The matrix is the source of truth, not staff memory.
Decision
If Auth required by the payer?
Resolved
Schedule the service.
Document the PA-not-required confirmation with the date and source (PA matrix version or payer rep name + reference number).
Decision
If Auth response received within 5 business days?
Resolved
Schedule. Save the auth number with the claim.
The auth number must appear on the claim. Save the approval letter with the patient record for the appeal package if a downstream denial occurs.
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