Prior authorization is usually completed by which party?

Prior authorization is primarily conducted by the healthcare provider, who is responsible for obtaining approval from the insurance company before a patient can receive certain medical services or medications. This process is essential for ensuring that the proposed treatment is deemed medically necessary and covered by the patient's insurance plan.

Healthcare providers must submit specific clinical information and treatment plans to the insurance company, demonstrating that the requested intervention meets the required criteria for coverage. This can involve providing medical records, justifying the necessity of the service, and adhering to the guidelines set by the insurance plan. By doing so, the healthcare provider helps ensure that the patient receives timely access to necessary care while minimizing the risk of claim denials.

In contrast, the patient typically participates by providing information and consent but does not complete the prior authorization process themselves. The insurance company reviews the request made by the provider to determine if it meets their coverage guidelines. A third-party administrator may assist or facilitate the prior authorization process but generally operates under the direction of the healthcare provider or insurance company.