What is true about prior authorization?

Prior authorization is an important process in healthcare that involves obtaining approval from a health insurance provider before a specific service or medication is delivered. The correct understanding about prior authorization is that it does not guarantee payment. This means that even if prior authorization is obtained for a service, there is still the possibility that the insurance company may deny the claim for payment later based on various factors, such as medical necessity or coverage limits.

This distinction is critical for healthcare access associates and others in the field as it underscores the importance of clear communication with patients about their coverage and potential out-of-pocket costs. Understanding that prior authorization merely indicates the insurance company is willing to consider the claim helps set realistic expectations for both providers and patients.

The other options do not reflect the true nature of prior authorization. It is not a guarantee of payment, is not limited to emergency services, and is not strictly categorized as a government mandate but rather varies across different insurance policies.