What does partial authorization mean?

When payers give medical providers authorization to provide care that is medically appropriate, it’s called full or partial authorization. Without authorization, your health plan company can deny services you need. Your healthcare provider’s office may have completed some forms requesting authorization before you received the service(s).

If this has happened, there are some reasons why this may have happened. Some reasons why your provider’s office will request authorization before you receive the service(s) is:

1. You or a family member has a pre-existing condition that requires treatment and/or follow up visits and your insurance company needs to approve the care before they will allow payment for it. This happens if you are new to a health plan company or are changing insurance companies.
2. You have a condition that will require treatment/follow up visits that is expected to last longer than six months. These conditions are usually chronic illnesses, such as asthma, high blood pressure, diabetes and others.
3. The services you received were not pre-authorized by the health plan company. In this situation, you or your provider may have contacted the insurance company after receiving treatment and they denied payment for the service(s). This is called post-service denials, which means a decision was made after you received care.

Partial Authorization: Partial authorization occurs when a health insurer denies coverage of a particular medical service(s) because the illness/condition is pre-existing.

4. The health plan company denies authorization for medical care that is not typically covered if you have no immediate need for it, such as non-emergency dental work, plastic surgery or sight corrections. This type of denial is called discretionary denials.
5. Your insurance company may deny payment for services if they determine that the service(s) are not medically appropriate.

Partial Authorization Definition: A health insurer denies coverage of a particular medical service(s) that are pre-existing conditions or are deemed not appropriate by the insurer. Partial authorization is when insurers approve some but not all the requested care.

6. The service(s) you received are not considered medically necessary, but your doctor feels they are important to improving your health and preventing future health problems.
7. You’re out of network (especially if you haven’t paid any deductibles).
8. There is a lack of medical necessity. Meaning the insurance company does not find the service(s) you’re receiving are appropriate for your health.

Full Authorization: Full authorization is when a health insurer approves all requested care. This can happen for many reasons, but typically pre-existing conditions are not an issue. Health insurance companies determine what is medically necessary and appropriate for your coverage. If the medical service(s) you’re receiving are deemed as non-covered (not medically necessary), that’s when your insurer will not pay for it.

9. The service(s) you received are not considered medically necessary, but your doctor feels they are important to improving your health and preventing future health problems.