UM Operations
Prior Authorization
Draft — pending verification
This reference entry has not yet been verified against its authoritative source (Original definitions; regulatory facts to be verified against CMS-0057-F (89 FR 8758) and X12/HL7 documentation). Do not rely on it for production configuration until this notice is removed.
In more depth
Operationally, prior authorization spans intake (portal, fax, phone, X12 278, FHIR API), clinical review against criteria, a determination (approve, partially approve, deny, pend), and communication of the decision with a certification reference providers use on claims. The term is used interchangeably with precertification and preauthorization in most contexts.