P
Definition
A requirement that the provider obtain approval from the health plan or broker before delivering the service. The PA confirms that the trip is medically necessary and covered under the member's benefit plan.
Overview
Why it Matters
Performing a trip without a PA number usually guarantees a denied claim. It is the financial "green light."
How it Works
A doctor or member requests a ride. The Broker/MCO reviews the medical necessity (e.g., "Why do you need a wheelchair van instead of a bus pass?"). If approved, a PA Number is generated and attached to the trip.
Code Comparison
Comparison: Prior Authorization vs. Pre-Certification
These are effectively synonyms in NEMT. PA is the standard term. Pre-cert is older insurance terminology.
Common Questions
- Expired PA: The PA was valid for dates 1/1 to 1/30, but the trip happened on 2/1.
- Level of Service Mismatch: The PA is for "Ambulatory" (A0100), but you provided and billed for "Wheelchair" (A0130). The claim will deny because the PA doesn't match the code.
- Configure software to "Hard Stop" dispatchers from scheduling a trip if the PA field is blank.
- Monitor "PA End Dates" for recurring dialysis patients and request renewals 14 days in advance.
Sources
AMA - Prior Authorization Practice Resources