Benefits verification versus prior authorization
Key Takeaway
Use Benefits Verification to check a patient's coverage and Utilization Management to get payer approval before a service is delivered. A provider with both problems needs both.
Benefits verification and prior authorization (PA) both help a provider get paid for care, but they answer different questions. Benefits verification tells the provider whether the patient's coverage is active and what it covers. Prior authorization is a request that the provider sends to the payer to approve a specific procedure or service before it happens. In Agentforce Health, prior authorization runs through Utilization Management (UM).
What each process does
Benefits and eligibility verification is the process of checking a patient's active health coverage with an insurance company, including which services are covered. With verification of benefits (VOB), providers can estimate what the patient owes and what the insurance reimburses based on contractual agreements.
Prior authorization is the process for determining whether a medical procedure or service is medically necessary and covered under the patient's insurance plan. Prior authorization is one of the managed care techniques in Utilization Management. Utilization Management lets payers manage the cost of health care benefits by judging a benefit's appropriateness before it is provided, using evidence-based criteria or guidelines.