5 prior authorization terms physicians should know, per the AMA

The American Medical Association has compiled a list of terms physicians should know involving prior authorization, the process requiring physicians to receive approval from the health plan before the prescribed treatment, test or medical service can be delivered to the patient.

Here are five of the terms included in the list:

Utilization management: the umbrella of insurer practices that prior authorization falls under, which is defined by the Institute of Medicine as the "set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision."

Step therapy: a policy required by payers where patients must first try lower-cost tests, drugs or other treatments before receiving higher-cost options.

Medical necessity: what determines whether a patient should or should not get a drug, test or surgery.

Peer-to-peer review: the process during which an ordering physician discusses with another physician who works with the payer the need for a procedure or drug.

Standard pharmacy electronic prior authorization: a capability that integrates prior authorization into a physician's electronic prescribing workflow to make it more efficient.

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