Administrative Requirements - Prior Authorization
The following are results from the National Health Insurer Report Card (NHIRC) for 2013 that deal with prior authorization.
Metric 7: Prior authorization frequency
Description: What is the frequency of prior authorization numbers on professional claims that were accompanied by an ERA with a payment greater than $0?
HCSC = Health Care Services Corporation
UHC = UnitedHealthcare
The AMA NHIRC results are based on data pulled from the nationally mandated Health Insurance Portability and Accountability Act of 1996 (HIPAA) electronic standard transactions. The technical references for these transactions are the electronic remittance advice (ERA) (HIPAA ASC X12 835 Health Care Claim Payment/Advice Transaction) submitted to a physician in response to the receipt of an electronic claim submission (HIPAA ASC X12 837 Health Care Claim--professional transactions).