APR 10, 2023
How Often Should We Confirm Prior Authorization Requirements?
In January, prior authorization was not required for a patient's intravitreal injection, and the claim was paid. In February, the claim was denied as requiring authorization. The payer representatives are telling us we need to check monthly as their plan benefits could change. Do we need to review their prior authorization policies for each patient monthly regardless of maintaining same plan coverage?
Answer:The Academy teaches to verify eligibility and benefits for every patient, every visit, including referral and prior authorization requirements. If plans do change, even within the same payer, the prior authorization policies may change as well.
Some commercial plans require prior authorization for both the procedure code and the drug. The drug may be authorized through a separate pharmacy portal.
Prior authorization resources and additional checklists can be found at
aao.org/retinapm.