What best describes prior authorization in utilization management?

• A. Prior authorization is payer approval required before certain services or medications; it helps ensure medical necessity and manage costs, potentially delaying care.
• B. Prior authorization is an optional step that rarely affects care.
• C. Prior authorization is a process of patient self-authorization.
• D. Prior authorization guarantees faster access.

Answer: (A)

Prior authorization is a payer-driven pre-approval step in utilization management. It requires approval before a specific service or medication will be covered, ensuring the treatment meets medical necessity and fits the payer’s cost guidelines. This review helps control costs and promote appropriate, evidence-based care. Because the decision depends on clinical documentation and may require alternative options or dosing, it can delay access to care while the review is completed. It is not optional or patient-driven, and it does not guarantee faster access; in fact, it can slow things down, though expedited processes may exist for urgent cases.