Prior Authorisation
Also written as: PA — Prior Authorisation
A mandatory payer approval process that must be completed before a prosthetic device is fabricated or delivered, confirming insurance coverage and medical necessity.
Full Definition
Prior authorization (PA) is a requirement imposed by health insurers, including Medicare and Medicaid, whereby a prosthetist or treating physician must submit clinical documentation — including functional assessments, diagnosis codes, and letters of medical necessity — before fabricating or dispensing a prosthetic device. The payer reviews the submission against coverage criteria and issues an approval or denial. Editors reviewing PA submissions must ensure clinical justification language is specific, diagnostic coding is accurate, and all required attachments are identified. The term is spelled 'authorization' in British English and 'authorization' in American English; editors should apply the style consistent with the target audience.
Usage
Usage note: In US contexts, 'authorization' (American spelling) is standard. Apply the document's house style consistently. Distinguish from 'certificate of medical necessity' (a separate billing form) and 'letter of medical necessity' (a narrative justification letter).
In Context
- "The prior authorization for the microprocessor-controlled knee joint was denied due to insufficient documentation of K3 functional capacity." — Insurance denial letter
- "Editors reviewing PA submissions should verify that ICD-10 diagnosis codes match those listed in the supporting clinical evaluation." — Editorial quality-control checklist