What is Prior Authorization?
Also called: pre-authorization · precert · prior auth
Authorization denials are among the most preventable and the most expensive, because they occur after the cost of delivering care has already been incurred.
Two operational details cause most failures: an authorization approved for a specific CPT code does not cover a different code billed after the procedure changed intraoperatively, and an authorization has both a unit count and an expiry date that a delayed or rescheduled service can quietly exceed.
Where Vizora handles this
Primary sources
Where "Prior Authorization" is defined by the bodies that set the rules, rather than by us.
- CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) (opens in a new tab)
Centers for Medicare & Medicaid Services — The rule imposing prior authorization decision timelines and API requirements on impacted payers. It is the single largest scheduled change to authorization workflow this decade.
- CAQH Index: cost of administrative transactions (opens in a new tab)
CAQH — Per-transaction cost of eligibility checks, claim status inquiries and prior authorization, manual versus electronic. The best public evidence for automating front-end work.
- Medicare Coverage Database (LCD/NCD) (opens in a new tab)
Centers for Medicare & Medicaid Services — Searchable national and local coverage determinations. The direct answer to whether a diagnosis supports medical necessity for a given procedure.
Last reviewed August 20, 2026
Related terms
Medical Necessity
Medical necessity is a payer's determination that a service was appropriate for the patient's condition under its coverage policy. It is established by the pairing of diagnosis and procedure codes and supported by the documentation — which means a medically necessary service can still be denied if the coding does not demonstrate it.
Eligibility Verification
Eligibility verification confirms a patient's active coverage, benefits, deductible status, copay, coinsurance and authorization requirements before the service is delivered. It runs electronically through the X12 270 inquiry and 271 response, and it prevents the largest single category of denials.
Denial
A denial is a claim the payer adjudicated and refused to pay. It differs from a rejection, which never entered adjudication. That distinction determines your remedy: a rejected claim is corrected and resubmitted, while a denied claim must be appealed within the payer's deadline.
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