Prior Authorization
Also written as: PA — Prior Authorization
A payer-required approval process that must be completed before a behavioral health service is rendered in order for reimbursement to be granted.
Full Definition
Prior authorization (PA) is a utilization management mechanism by which insurance payers review the medical necessity of a proposed behavioral health treatment before approving coverage. In behavioral health settings, PA requests are required for services such as inpatient psychiatric admissions, residential treatment, intensive outpatient programs, and certain psychotropic medications. Clinical writers must provide sufficient diagnostic evidence, symptom severity data, and failed lower-level-of-care documentation to support approval. Editors reviewing PA letters must ensure that clinical justification language is specific, meets payer criteria, and avoids vague descriptors. The term is two words (no hyphen) as a noun phrase; 'preauthorization' is an acceptable synonym used by some payers.
Usage
Usage note: Two words, no hyphen, as a noun phrase. When used attributively before another noun, hyphenate: 'prior-authorization request.' Do not abbreviate to PA without definition at first use, as PA has multiple meanings in healthcare.
In Context
- "The clinical team submitted a prior authorization request citing the client's PANSS score and failed outpatient treatment history." — Insurance authorization letter
- "The editor flagged the prior authorization letter for vague symptom language that would likely result in a payer denial." — Editorial review workflow