Predetermination vs prior authorization
An authorization answer is not a coverage, eligibility, or payment answer. Substrate does not submit prior authorization requests.
Prior authorization and coverage
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
HealthCare.gov preauthorization glossary
The glossary says preauthorization is not a promise that the plan will cover the cost. An authorization result on Substrate does not establish coverage, eligibility, or payment.
Comparison
| Question | What this page can say |
|---|---|
| Prior authorization | Use the HealthCare.gov glossary quoted above. A code row that is not approved is not a determination. |
| Coverage and payment | The glossary says preauthorization is not a promise the plan will cover the cost. Do not read an authorization row as payable. |
| Eligibility | This page does not verify eligibility and does not turn an authorization row into an eligibility answer. |
| Medical necessity | The glossary uses “medically necessary” inside the preauthorization definition. This page does not search medical policy. The existing medical-necessity resource stays the owner of that topic. |
| Predetermination | Predetermination is a different question from prior authorization. This page does not answer it with an authorization row. The existing pre-procedure policy resource stays the owner of that topic. |
Pre-procedure payer policy review
Blue Cross and Blue Shield of Illinois utilization management