Prior Authorization
Payer requirement that the practice obtain approval before delivering certain services, procedures, or drugs.
1 min read · Last reviewed May 23, 2026
At a glance
- Category
- Payer
- Primary sources
- 1
- Workspace handoff
- denial workbench →
Where this comes up
Front-office and billing both hit this term — eligibility before the visit, prior auth before the procedure, contract terms during fee-schedule negotiation, and credentialing whenever a new provider joins or a payer roster lapses. Misses here become denials downstream.
Full definition
What it is in practice
Prior authorization is a utilization management tool. CMS has been incrementally regulating prior-auth processes for MA, including the 2024 CMS Prior Authorization Final Rule.
How it shows up in your practice
Build a prior-auth tracking system. Time spent obtaining prior auths is a measured productivity drain — make sure you bill the appropriate service codes (e.g., when a chronic care management code captures the time).
Sources
- CMS — Medicare Advantage (Part C)https://www.cms.gov/medicare/health-plans/medicareadvtgspecratestats
Track prior auths in the Denial Workbench
Open denial workbench →Related terms
- PayerMedicare Part C (Medicare Advantage)Medicare benefits delivered through private health plans contracted with CMS, often with additional benefits and a managed-care structure.
- Denials & AppealsDenial ManagementThe end-to-end workflow of identifying, categorizing, appealing, and preventing claim denials.
- PayerStep TherapyA payer requirement that less expensive drug or service options be tried before more expensive alternatives are covered.
- CodingMedical NecessityThe standard requiring that services be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
D3rx is a healthcare-billing and compliance research aid maintained by D3rx Inc. Articles are drafted by an LLM (Anthropic Claude) against primary HHS, OCR, CMS, eCFR, NIST, and state-regulator publications, and reviewed for restraint and source fidelity by the D3rx team.
Reviewer status: a named credentialed reviewer (CHC, CHPC, or healthcare attorney) is being engaged. Until that engagement is finalized, this page does not claim credentialed review.
Related across the archive
- GlossaryMedicare Part C (Medicare Advantage)Medicare benefits delivered through private health plans contracted with CMS, often with additional benefits and a managed-care structure.
- GlossaryStep TherapyA payer requirement that less expensive drug or service options be tried before more expensive alternatives are covered.
- GlossaryDenial ManagementThe end-to-end workflow of identifying, categorizing, appealing, and preventing claim denials.
- GlossaryMedical NecessityThe standard requiring that services be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
- GlossaryACA Marketplace PlanHealth plans sold through the federal or state-based health insurance marketplaces under the Affordable Care Act.
- GlossaryMedicare Stars RatingFive-star quality rating system CMS publishes annually for Medicare Advantage and Part D plans.
- GlossaryMental Health ParityFederal and state laws requiring health plans to apply benefits and access requirements to mental health and substance use treatment that are no more restrictive than those for medical/surgical care.
- ComplianceOIG LEIE Monthly Exclusion Screening: Process + Audit-Ready LogsMonthly OIG LEIE and SAM.gov exclusion screening for every workforce member and vendor: the workflow, the log fields auditors require, and the escalation path.
This glossary entry is a research aid for billing and compliance staff. It does not provide legal, medical, or financial advice and does not replace counsel. References cited link to primary sources at HHS, OCR, CMS, eCFR, NIST, and the relevant payer or industry body.