Prior authorization and post-service review

Prior authorization happens before the service; the claim is the downstream step. This policy governs what a post-service audit may and may not revisit once an authorization exists.

All policies

Current version

v3.4

in force since 2025-11-01 · as at 2026-04-02

Versions on file

back to 2024-09-01

Applies to

All lines of business

All states, with variations

Cited in this batch

claims tested against it

Where this sits

OwnerUtilization Management Policy

Lines of businessAll lines of business

StatesAll states, with variations

External basisCMS Interoperability and Prior Authorization final rule (CMS-0057-F) · state prior-authorization statutes

Variations by state and line of business

The same policy reads differently depending on where the member is covered and under which programme.

Texas: HB 3459 gold-carding exempts qualifying providers from prior authorization for specified services; an exempt provider's claim is not treated as unauthorised.

Medicaid: emergency services are not subject to prior authorization in any state this plan operates in.

Version history

Newest first

A claim is tested against the version that was in force on its date of service. For a service last autumn, that is not the version at the top of this list.

v3.4 2025-11-01 → current In force now

An approved authorization now bars post-service medical-necessity review of the authorised service. Coding and pricing accuracy remain reviewable, as does a claim that exceeds what was authorised.

Extracted from CPP-085_prior-authorization-post-service-review_v3.4.md — 3 pages, indexed under __live__, so a finding on this version can quote it.

A service with an approved authorization on file is not denied post-service for medical necessity.
Units, dates and sites billed beyond those authorised are reviewable and recoverable.
A service requiring authorization with none on file is recoverable in full, subject to the state's gold-carding rules.

v3.3 2024-09-01 → 2025-10-31 Superseded

Baseline. Post-service medical-necessity review was permitted regardless of an authorization.

No source document in the index. A finding on this version can cite it by name but cannot quote a passage.

An authorization does not bar post-service review.

Claims in this batch tested against this policy

6 of 25

Claim	Date of service	Version applied	Role	Paid	At risk
CLM-0000006	13 Mar 2026	v3.4	Decisive	$512.88	—
CLM-0000021	19 Mar 2026	v3.4	Supporting	$8,069.76	$1,344.96
CLM-0000022	10 Mar 2026	v3.4	Supporting	$316.97	—
CLM-0000023	23 Mar 2026	v3.4	Supporting	$191.72	—
CLM-0000024	24 Feb 2026	v3.4	Supporting	$3,083.85	—
CLM-0000025	05 Mar 2026	v3.4	Supporting	$254.18	$254.18

This policy is synthetic — an internal document written for this demo. The external basis it cites is real.