What does pre-authorization typically apply to in managed care?

Pre-authorization is a process used by managed care organizations to determine if a particular service, procedure, or medication will be covered under a patient’s health plan before it is provided. This process is typically required for services that are not urgent or emergent in nature.

Elective hospital admissions are often subject to pre-authorization because these types of admissions are planned and not immediately necessary for the patient's health. The managed care organization wants to ensure that the admission is medically necessary and aligns with their coverage guidelines. This helps control costs and ensure that patients receive appropriate care.

In contrast, routine check-ups, emergency services, and preventive care visits usually do not require pre-authorization. Routine check-ups and preventive care are generally preventative measures covered under most health plans without prior approval. Emergency services are also treated differently; they are typically covered immediately since the situation requires prompt action without the delay of obtaining pre-authorization, reflecting the urgent need for care in such situations.