If a service requires pre-authorization and it is not obtained, what is a likely consequence?

• A. The claim may be denied or require correction or patient responsibility.
• B. The service will be paid in full anyway.
• C. The payer will retroactively approve automatically.
• D. There is no effect on payment.

Answer: (A)

Prior authorization is a gatekeeper step used by many payers to verify that a service will be covered based on medical necessity before it’s performed. If that pre-authorization isn’t obtained, the payer is likely to deny payment for the service or require the claim to be corrected or resubmitted with proper authorization. In practice, this often means the patient may be responsible for the cost if the service isn’t covered without prior approval. A retroactive approval or automatic full payment is not typically expected, since coverage hinges on having the prior authorization in place.