Medical Insurance 7th Edition by Amy Blochowiak, Joanne Valerius, Nenna Bayes, Cynthia Newby

Exercise 8

Read the following preauthorization policy from a typical PPO plan and answer the questions that follow:
Preauthorization is the process of collecting information prior to inpatient admissions and selected ambulatory procedures and services. The process permits advance eligibility verification, determination of coverage, and communication with the physician and/or member. It also allows the PPO to coordinate the member's transition from the inpatient setting to the next level of care (discharge planning), or to register members for specialized programs like disease management, case management, or maternity management programs. In some instances, preauthorization is used to inform physicians, members, and other healthcare providers about cost-effective programs and alternative therapies and treatments.
Certain healthcare services require preauthorization under this plan. When a service requires preauthorization, the provider is responsible to preauthorize those services prior to treatment. However, if the patient's plan covers self-referred services to network providers or self-referrals to out-of-network providers, and the patient is able to self-refer for covered benefits, it is the member's responsibility to contact the plan to preauthorize those services.
A. What does the plan state are the purposes of preauthorization?
B. In your own words, define self-refer.
C. Under what circumstances is it the patient's responsibility to obtain preauthorization approval?