Glossary, billing and revenue
What is prior authorisation?
Prior authorisation is an insurer's approval, given before a treatment, test or prescription, that it will pay for that care. The clinic asks for it with the clinical reasons, and without it the claim can be refused after the patient has been seen.
Updated . Defined by the wai team for clinics, groups and health systems.
Also called prior authorization, pre-authorisation or pre-approval.
Why Prior authorisation matters to a clinic
A refused authorisation is the most expensive kind of denial, because the work is already done when the refusal arrives. For a clinic billing insurers, every missing authorisation is either a written-off visit or a bill the patient did not expect.
Most refusals come back to the documentation. The insurer wants the diagnosis, the history and the reason this treatment is needed now, in the terms it uses, and a request built from a complete, signed note is far more likely to be approved first time.
Questions
Is prior authorisation the same as pre-certification?
The terms are used for the same step in many markets. Both mean the insurer agrees in advance that it will pay for a planned treatment.
Who is responsible for getting it?
Usually the clinic or the treating clinician, though the patient carries the cost if it is missed. Check each insurer's rules, which differ by plan and by treatment.
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