Which process involves reviewing a patient's medical necessity for a proposed service?

The process of pre-authorization is essential in determining a patient's medical necessity for a proposed service. This step generally requires healthcare providers to submit documentation to the insurer outlining the reasons why a specific treatment or service is needed based on the patient's current medical condition. The insurance company then evaluates this information to decide whether they will cover the proposed service.

This ensures that the service is warranted and meets the criteria set out by the insurer's policies. By requiring pre-authorization, insurance companies aim to ensure that patients receive appropriate and necessary care while also controlling costs and preventing unnecessary procedures.

Other processes such as claims processing, billing validation, and patient follow-up involve different aspects of healthcare reimbursement. Claims processing deals with the submission and handling of claims after services have been rendered, billing validation focuses on ensuring the accuracy and completeness of billing information, and patient follow-up typically involves checking on the patient’s progress and satisfaction after care has been provided. None of these processes specifically target the assessment of medical necessity prior to service provision in the way that pre-authorization does.