Pre-Authorizations – What Are They and How Do They Work? 

Pre-authorizations are a piece of the billing puzzle, helping to determine whether your client’s visit with you is deemed medically necessary. Let’s take a step back to explore this process and when these have to be conducted on behalf of your client. 

First, you know that conducting eligibility estimates is an important piece in the billing process, which help estimate what you'll get reimbursed by insurance companies. Eligibility estimates are how you know from the get-go if your client is covered by his/her plan for your nutritional counseling services. Sometimes, insurance may need additional information to determine whether your nutrition counseling service is medically necessary. This is called a pre-authorization – you’ll sometimes hear this referred to as simply an authorization or a prior authorization

Your billing ally at Healthy Bytes provides the insurance company with the code and diagnoses that will be submitted as part of your claim. The information is reviewed by a nurse advisory team at the insurance company to check for medical necessity, plus allowable and billable codes. 

The advisory team may determine that your client can be approved for eight visits with you over the next six months for nutrition counseling specific to his/her hyperlipidemia and diabetes, for example. They provide Healthy Bytes with a case number, which we attach to the claim to be submitted. We flag any pre-authorizations for you, so that you can wait to see your client until he/she has been approved for your services. 

When Should an Eligibility Estimate and Subsequent Pre-Authorization be Conducted?

Healthy Bytes conducts eligibility estimates the first time that you see a client. While they aren't a guarantee of coverage, eligibility and benefits estimates can give us a lot of useful info, including co-pays and deductibles. Let us know when you have obtained a new client so that we can request eligibility estimates as soon as possible. This way, if we need a pre-authorization, we’ll have time to gather it before your first appointment. 

As a best practice, eligibility estimates and any necessary pre-authorizations should be taken care of prior to seeing your new client. Your Healthy Bytes billing ally can help you determine absolute necessity, however, as sometimes the rate of requests for pre-authorizations depends upon the insurance company. 

Rates of approval for Pre-authorizations

The majority of the pre-authorizations that the Healthy Bytes team submits are approved. Keep in mind again, however, that just because a pre-authorization has been approved does not mean that your claim will be approved. We know, this can be frustrating! That’s why we’re here to serve as your billing liaisons – we’ll manage the interaction with the insurance companies on your behalf and fight for your reimbursement so that you don’t have to!

What questions do you have about pre-authorizations?