Prior authorization glossary

The CMS-mandated maximum turnaround time for expedited (urgent) prior authorization decisions under CMS-0057-F.

The CMS-mandated maximum turnaround time for standard (non-urgent) prior authorization decisions under CMS-0057-F.

The time, labor, and cost healthcare organizations spend on non-clinical tasks like prior authorization, billing, and documentation, frequently cited as a major driver of clinician burnout and delayed care.

The portion of U.S. healthcare spending attributed to non-clinical processes like prior authorization, frequently cited in cost studies as tens of billions annually.

AI-driven decision-making where each step of a determination (data used, rule applied, outcome reached) can be traced and reviewed after the fact, as opposed to an opaque or "black box" output.

PA requirements specific to mental health and substance use treatment, an area facing fresh federal scrutiny and considered harder to automate accurately due to documentation variability.

Any postponement in treatment, medication access, or procedure scheduling caused by pending prior authorization.

Revenue a provider organization cannot collect or must delay collecting due to pending, denied, or improperly documented prior authorizations.

The stage of Ethermed's workflow that identifies whether a given service or medication requires prior authorization before work begins, reducing wasted effort on non-PA-required cases.

The percentage of claims submitted without errors that would trigger denial or delay, closely tied to upstream prior auth accuracy.

The CMS rule requiring impacted payers (Medicare Advantage, Medicaid, CHIP, QHP issuers) to meet specific prior auth turnaround times, support FHIR-based electronic PA, and publicly report denial rate metrics.

The process of determining, before a claim or request is submitted, whether a specific service requires prior authorization and what payer-specific rules apply.

The workflows and systems providers use to track, appeal, and resolve denied claims and prior authorizations.

The percentage of prior authorization requests that are not approved, now subject to public reporting requirements for many payers.

The digital, API-driven version of prior authorization that replaces manual fax- and phone-based submission with structured data exchange between providers and payers, typically built on FHIR standards.

A prior auth decision (approval, denial, or pend) accompanied by a clear, traceable rationale tied to the specific payer policy or clinical criteria applied.

The technical standard healthcare systems use to exchange data electronically, including the data structures required for electronic prior authorization under federal rules.

A standardized, payer-specific data structure that defines exactly what clinical documentation is required to support a given prior authorization request, replacing inconsistent PDF forms and payer-specific portals.

The stage that generates the compliant prior authorization submission using matched clinical data.

The percentage of prior authorization requests approved on initial submission without additional documentation requests, denials, or peer-to-peer review.

A payer policy that exempts high-performing providers from prior authorization requirements for certain services, based on their historical approval rates.

The ONC health IT certification rule that codifies the technical criteria (Coverage Requirements Discovery, Documentation Templates and Rules, Submission and Status Tracking) that certified health IT systems must support for electronic prior authorization.

Subsequent ONC rulemaking addressing deregulation and adjustments to health IT certification requirements following HTI-4.

The stage that aligns patient clinical data against payer-specific documentation and medical necessity requirements.

The clinical standards a payer uses to determine whether a requested service or medication is appropriate and required for a patient's condition.

The requirement that health plans apply prior authorization and utilization management to behavioral health services no more stringently than to medical/surgical services.

The specific clinical criteria and documentation requirements a health plan uses to evaluate prior authorization requests, which vary payer to payer and often change without notice.

A conversation between a provider and a payer's medical director, typically triggered by an initial denial, to clinically justify a requested service or medication.

Instances where patients discontinue or delay care because of prior authorization friction, documented as a driver of poor outcomes and non-adherence.

The formal process a provider initiates to challenge a denied authorization, often requiring additional clinical documentation.

The volume of pending, unprocessed authorization requests a payer or provider is working through, often cited as a symptom of manual/legacy systems.

A requirement from health insurers that providers obtain approval before performing certain procedures, prescribing certain medications, or delivering certain services, confirming medical necessity and coverage before care is delivered.

The cumulative staff time, delayed care, and revenue delay providers absorb from manual PA submission, follow-up, and appeals across multiple payers with different requirements.

The CMS requirement that impacted payers publicly disclose their prior authorization approval and denial statistics annually.

The relationship between accurate PA documentation and payer risk models, relevant to value-based care arrangements.

The stage that transmits the completed submission through to the payer, closing the loop from identification to submission.

Prior auth requirements specific to high-cost specialty medications, infusion therapies, and controlled substances, typically more complex than standard medical PA.

The interval between service delivery (or scheduling) and payment collection, directly affected by prior auth turnaround speed.

A prior authorization request that is submitted, reviewed, and approved without manual human intervention on the provider or payer side.

The time elapsed between a prior authorization request submission and a payer's final determination, now subject to regulatory maximums.

The broader payer function that includes prior authorization, concurrent review, and retrospective review to ensure appropriate use of healthcare services.