Who determines prior authorization for payment of a medical procedure?

Who determines prior authorization for payment of a medical procedure?

• A. The patient
• B. The medical insurance company
• C. The hospital
• D. The physician

Answer: (B)

Prior authorization is the insurer’s decision about whether a requested medical procedure will be paid under the patient’s policy before the service is performed. Although a physician or clinic can initiate the request and provide supporting medical documentation, the final decision rests with the payer after they review medical necessity, coverage, and plan rules. The patient may request or discuss options, but the responsibility for approving payment lies with the medical insurance company, not the hospital or the physician.

Prior authorization is the insurer’s decision about whether a requested medical procedure will be paid under the patient’s policy before the service is performed. Although a physician or clinic can initiate the request and provide supporting medical documentation, the final decision rests with the payer after they review medical necessity, coverage, and plan rules. The patient may request or discuss options, but the responsibility for approving payment lies with the medical insurance company, not the hospital or the physician.