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Determine If a Prior Authorization is Required
Prior Authorization refers to the process whereby Presbyterian's Health Services Department reviews and approves the provision of certain covered services to members before those services are rendered.
- A member may call in to ask if a service requires prior authorization.
- Follow the steps below to assist the member with their prior authorization request.
- Confirm the service is a covered benefit.
- Ask probing questions.
- Do you have the CPT/HCPCS code
- What is the name of the service/procedure
- Where will you be receiving this service
- What is the providers name
- Navigate to the reference section of the Medicare page and select the Prior Authorization/ Benefit Certification Guide.
Note: All of the following services require PA:
- Inpatient admission
- Hospice care except for inpatient hospice care at Presbyterian Kaseman Hospital
- Skilled nursing facility admission
- Home health care
- Transition of Care for OON Provider