Prior authorization is a plan's advance review of whether a proposed service meets its coverage criteria. It may be required for certain wound products, procedures, tests, equipment, or out-of-network care, but an authorization is not a guarantee that the plan will pay the eventual claim.
Requirements vary by plan and may apply to NPWT, cellular and tissue-based products, molecular tests, specialty drugs, repeated procedures, DME, or home-based services. Original Medicare and Medicare Advantage do not use identical prior-authorization rules.
The submission may need diagnosis and procedure codes, measurements, wound duration and cause, photographs when allowed, perfusion and infection assessment, prior conservative treatment and response, product quantity, frequency, and clinical rationale.
An approval can be limited to a provider, product, number of units, date range, or place of service. A denial should identify the coverage criterion and review rights. Urgent or expedited review may be requested when the plan's standard timeframe could jeopardize life, health, or function.
Payment also depends on active coverage on the service date, network status, correct coding, documentation, benefit limits, coordination of benefits, and patient cost sharing. Keep the authorization number and decision letter, but never treat them as a payment guarantee; request a cost estimate and appeal an adverse decision when appropriate.
Call 877-545-1300 or request a provider to begin care. Healix360 serves Southern California and Nevada and accepts Medicare Part B and most major insurance plans.