Prior auth has enough acronyms.
Here’s what they mean.

A payer review required before certain drugs, services or procedures can be covered. Approval means the request met the payer’s requirements at that point in time. It is not a guarantee of final payment.

The check that confirms a patient’s insurance coverage is active for the date of service. Think: “Is this plan currently in force?”

A deeper look at what the patient’s plan covers, including benefits, expected patient responsibility & whether prior authorization or other pre-service review may be required.

A pre-service payer review used by some plans to assess whether a proposed service appears to meet coverage requirements. It may look a lot like PA, but the rules vary by payer.

The organization responsible for administering or paying a patient’s health benefits, such as a commercial insurer, Medicare Advantage plan or Medicaid managed-care plan.

The specific insurance product covering the patient. Two patients with the same parent insurer can have very different PA rules because their plans differ.

The payer’s rules for when a drug, procedure or service qualifies for coverage. Criteria may include diagnosis, stage, biomarkers, prior therapies, dose, site of care or other clinical details.

An evidence-based recommendation for clinical care, such as an oncology treatment guideline. Guidelines inform care, but they are not the same thing as a payer’s coverage policy.

The clinical rationale supporting why a service or treatment is appropriate for the patient under the payer’s coverage rules.

A coverage rule requiring the patient to try a preferred treatment before the payer will cover another option, unless an exception is approved.

The information sent to a payer for review. It can include the order, diagnosis, clinical notes, labs, imaging, pathology, biomarkers, prior treatment history & payer-specific forms.

The clinical or administrative records used to show that a request meets payer requirements. Missing or unclear documentation is a common source of rework.

A payer request for additional information before making a decision. The clinic may need to find records, clarify documentation or provide another form before review can continue.

The point when the PA request is actually sent to the payer through a portal, API, clearinghouse, fax, email or another accepted channel.

The time between a clinical order being placed & the PA request being sent to the payer. Useful for measuring clinic-side workflow delay.

The elapsed time for a defined part of the PA process. Always ask what starts & stops the clock, because “TAT” may mean submission-to-decision, order-to-approval or something else.

The time from PA submission until the payer returns a determination or other meaningful response.

The time from a defined starting point, such as treatment order or first oncology visit, until the patient can begin therapy. It includes more than payer review alone.

The payer’s decision or disposition on a request, such as approved, denied, partially approved or requiring more information.

A payer determination that the requested service meets the applicable authorization requirements. Approval may include limits on dates, units, dose, site or duration.

The identifier issued by a payer for an approved authorization. Clinics use it to track the approval & support downstream billing.

The period during which an approval is valid. Treatment outside the approved dates, units or conditions may require an update or new authorization.

A payer decision not to approve the request as submitted. Reasons can include missing information, coverage criteria, coding, step therapy, plan rules or other requirements.

The first negative payer decision. It is different from an ultimate denial because some cases are later approved after additional documentation, a P2P or an appeal.

A request that remains denied after the applicable review, reconsideration or appeal process is complete. This is not interchangeable with initial denial rate.

Extra work required because a request could not move forward as submitted, such as correcting information, finding documentation, responding to an RFI or changing the submission.

Sending a PA request again after correcting, adding or changing information. Repeating the same request without addressing the denial reason can create expensive loops.

A clinical discussion between the treating or ordering provider & a payer clinician about a coverage decision. A P2P may resolve a denial, but an overturn is not guaranteed.

A formal request asking the payer to reconsider a denial. Appeals may include additional clinical evidence, a medical-necessity argument & documentation addressing the denial reason.

A clinician-reviewed explanation of why a requested treatment or service is medically appropriate, often submitted as part of an appeal or exception request.

The percentage of requests that move through their first submission without needing correction or rework. Define this carefully because “accepted” does not always mean “approved.”

The percentage of submitted PAs approved on the initial review without an appeal, P2P or resubmission. The denominator should always be stated.

A human or system action taken on a PA, such as opening a chart, attaching a document, checking a portal, calling a payer or updating a status.

A case that cannot follow the normal workflow & needs additional review or action, such as missing records, an unusual regimen, an off-label indication or a payer without an automated pathway.

A defined expectation for how quickly a process or service should be completed. In PA workflows, teams may track internal targets separately from payer turnaround requirements.

The distribution of insurance plans across a practice’s patients. Payer mix matters because authorization requirements, reimbursement & workflow burden can vary substantially by plan.

The financial workflow from patient registration & coverage verification through coding, claims, payment, denials & collections.

Money owed to the practice for services already delivered but not yet collected.

A revenue-cycle measure of how long receivables remain outstanding. PA problems can contribute to downstream issues, but A/R is also affected by coding, claims, payer processing & collections.

Grouping unpaid receivables by how long they have been outstanding, commonly into buckets such as 0–30, 31–60, 61–90 & 90+ days.

A claim submitted with the information needed for processing without errors or missing elements that would cause avoidable rejection or rework.

Electronic health record. The clinical system where diagnoses, notes, orders, labs, imaging & treatment information are documented.

The system commonly used for patient registration, scheduling, insurance, billing & financial information. In some oncology practices, it is the source of truth for administrative data even when the EHR holds the clinical record.

Fast Healthcare Interoperability Resources, an HL7 standard for exchanging healthcare information between systems through structured resources & APIs.

A standards-based framework that allows applications to launch securely with authorized EHR context, such as the current patient or user.

A healthcare electronic data interchange transaction used for certain referral & healthcare-service review requests and responses, including authorization workflows.

The HL7 Da Vinci Prior Authorization Support implementation guide, which uses FHIR-based workflows to help exchange prior authorization information between providers & payers.

Protected health information. Individually identifiable health information protected under HIPAA when handled by covered entities & applicable business associates.

Business Associate Agreement. A HIPAA-required contract used when a business associate handles PHI on behalf of a covered entity, describing permitted uses & required safeguards.

A record of who or what accessed, changed, reviewed or transmitted information & when. Useful for security, compliance, troubleshooting & workflow analysis.

A workflow where people remain responsible for reviewing, correcting, approving or overriding AI-supported actions at defined points.

The ability to trace an extracted or generated statement back to the underlying chart, pathology report, imaging result, lab, policy or other source used to support it.

Looking beyond the final denial or delay to identify where the workflow actually broke, such as missing records, payer rules, coding, provider action, submission timing or follow-up.

A defined sequence of events tied to one authorization need, from order or intake through submission, payer activity, escalation & final disposition. Defining the episode clearly keeps analytics from mixing unrelated work.