Prior authorization software assists healthcare providers and health insurance companies in the medical care authorization process. These insurance companies require healthcare clinicians and providers to receive preapproval for certain procedures, tests, or medications. The care plan must be evaluated to assess the medical necessity and cost-of-care ramifications before authorization. If the provider fails to get prior authorization, the insurer will not cover the cost of treatment, and the patient may have to bear the cost.
The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patient’s insurance provider. This helps determine if prior approval is required for a given procedure and to submit the actual prior authorization paperwork to the insurance company for review and approval. Obtaining prior authorization is an administrative burden for any medical practice, and this software helps streamline the process.
Prior authorization software enables EHR software or patient relationship management (PRM) software to automatically determine if prior approval is required, electronically submit the prior authorization directly to the insurance company, and actively monitor the status of the submission. Prior authorization software can be paired with patient intake software and revenue cycle management software.
To qualify for inclusion in the Prior Authorization category, a product must:
Utilize some form of artificial intelligence or rules-based automation to assess the patient’s insurance and its associated services
Integrate with the insurance company portals, eFax, or other hybrid methodology that relieves the healthcare provider of the burden
Handle the submission and approval process, including form submission and communication between healthcare providers and insurance companies
