Preauthorization review

A preauthorization records a request against a policy and organization. It can carry a member reference, request date, requested benefit and clinical evidence. Policy Operations Specialist prepares the request, while Preauthorization Reviewer checks the submitted revision and records the insurer-confirmed outcome. The review decision is recorded against the parent policy with a reviewer and reason, separate from the request status. Match its operation key and receipt to the submitted request before using that decision as the request outcome.

A request can be draft, submitted, approved, rejected or completed. Moving to submitted establishes the version to review. An independent team member should check the supporting evidence, scope and policy context before a decision is recorded. A preauthorization is a decision about the requested benefit; a later claim and its paid evidence follow their own records.

• Prepare the request. Link the correct policy and organization, then record the member reference, requested amount and supporting evidence.
• Review one revision. Read the submitted version and record the reviewer, source revision, decision date and reason.
• Confirm the result. Keep the resulting status and operation receipt with the policy, and match the receipt to the request and review decision so a retry can be reconciled.

Agree which insurer or clinical authority supplies the supporting decision and how that confirmation reaches the team. Define who may submit a request, who may review it and how independence is checked. Set a rule for changed evidence after submission: the reviewer should decide against a stable version, while the preparer can correct and resubmit a returned case.

Decide what “completed” means for local operations. The team may need a receipt showing that the intended effect matches the request revision; a completed record should never stand in for a verified claim payment. Record the organization scope on the request as well as the parent policy and test mismatched scope during rehearsal.

A policyholder requests confirmation for a covered service. Policy Operations Specialist links the policy, enters the member reference and requested benefit, and attaches the clinical evidence to the policy context. Preauthorization Reviewer opens the submitted request and checks that the policy and organization match. If the evidence supports the insurer’s approval, the reviewer records the approving decision, date and reason against that revision. If the evidence is incomplete, the reviewer returns or rejects the case according to the insurer’s process.

Rehearse a changed request after submission. The old review must not authorize the new revision. Repeating the same operation key should resolve to the prior effect, while a mismatch in revision or scope should remain visible for investigation. Claims staff can later read the request as context without treating it as proof of settlement.

• Submitted preauthorizations — Work through requests ready for independent review.
• Preauthorization outcomes — Read decisions and completion states against their parent policies.

Follow a preauthorization decision and review decision authority.