CPP-085_prior-authorization-post-service-review_v3.4.md

# CPP-085 — Prior authorization and post-service review **Version 3.4 · Effective 1 November 2025 · Supersedes v3.3** Owner: Utilization Management Policy Applies to: All lines of business — all states, with variations External basis: CMS Interoperability and Prior Authorization final rule (CMS-0057-F) · state prior-authorization statutes ## 1. Purpose 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, and what happens when one is required and absent. ## 2. What changed in version 3.4 Version 3.3 permitted post-service medical-necessity review regardless of whether an authorization had been granted. That created a second bite at a decision the plan had already made, and it is withdrawn. From 1 November 2025 an approved authorization bars post-service medical-necessity review of the authorised service. Coding and pricing accuracy remain reviewable in

lready made, and it is withdrawn. From 1 November 2025 an approved authorization bars post-service medical-necessity review of the authorised service. Coding and pricing accuracy remain reviewable in every case, as does a claim that exceeds what was authorised.

## 3. Criteria ### 3.1 An authorization on file A service with an approved authorization on file, performed within the authorised date range and at the authorised site, is not denied post-service for medical necessity. A reviewer who believes the authorization was granted in error refers the matter to utilization management; it is not a claim finding. ### 3.2 What remains reviewable An authorization certifies that the service was appropriate. It does not certify how the service was coded or priced. The following remain reviewable on an authorised service: - the level, severity tier or unit count billed; - the fee schedule, allowable or relative weight applied; - duplicate or unbundled lines; - the place of service and the rendering provider. ### 3.3 Units, dates and sites beyond the authorization Units, dates and sites billed beyond those authorised are reviewable and recoverable, whether or not the underlying therapy was approved. The excess is the recoverable amount; the

d the authorization Units, dates and sites billed beyond those authorised are reviewable and recoverable, whether or not the underlying therapy was approved. The excess is the recoverable amount; the authorised portion is not disturbed. ### 3.4 No authorization on file A service requiring authorization with none on file is recoverable in full, subject to section 4.

## 4. Variations by state and line of business ### 4.1 Texas — gold-carding Texas House Bill 3459 exempts a provider whose prior-authorization requests for a given service were approved at or above the statutory rate in the preceding evaluation period from having to obtain authorization for that service. An exempt provider is recorded in the gold-carding register. A claim from an exempt provider for a qualifying service is not treated as unauthorised, and section 3.4 does not apply to it. The absence of an authorization is not an authorization gap where the exemption is on file for the provider, the service and the date of service. ### 4.2 Emergency services Emergency services are not subject to prior authorization in any state in which this plan operates. A retrospective authorization requirement may not be applied to an emergency presentation. ### 4.3 Medicare Advantage Where the Medicare Advantage organisation has adopted a coverage criterion that is more restrictive than

ation requirement may not be applied to an emergency presentation. ### 4.3 Medicare Advantage Where the Medicare Advantage organisation has adopted a coverage criterion that is more restrictive than traditional Medicare, that criterion may not be applied post-service to a claim it authorised prospectively.