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Billing Terms Glossary

Prior Authorization Terms: Definitions for Therapists and Psychiatrists

These prior authorization terms are defined in plain English for therapists and psychiatrists. Prior authorization terms describe how payers approve care before or during treatment. These definitions cover authorization types, utilization review, level of care, and medical necessity criteria. Use these authorization terms when you ask a payer whether a service needs approval first. Rules differ by payer, plan, and state, so confirm the requirement with the payer before you schedule the service.

In this section

16 terms defined
Written for psychotherapists and psychiatrists
Source organization linked on every entry

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Authorization Date Range

General (all payers)

Also called: auth span; approved dates

Definition: The start and end dates for which an authorization is valid.
Why it matters: Services outside the span deny.
Illustrative example: A session occurs after the authorization ended.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Prior Authorization Terminology

Authorization Number

General (all payers)

Also called: auth number; reference number

Definition: The identifier a payer assigns to an approved authorization, often required on the claim.
Why it matters: A missing or wrong number causes denials.
Illustrative example: The claim lists the auth number in the prior authorization field.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Prior Authorization TerminologyClaims Processing

Authorization Request

General (all payers)

Also called: auth request; precert request

Definition: A submission to a payer asking for approval, with clinical information and requested services.
Why it matters: Complete, specific requests reduce denials and delays.
Illustrative example: A biller submits diagnosis, codes, dates, and notes with the request.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Prior Authorization Terminology

Authorized Units

General (all payers)

Also called: approved visits; authorized sessions

Definition: The number of visits, units, or days a payer approved under an authorization.
Why it matters: Billing beyond authorized units leads to denials.
Illustrative example: An authorization covers 8 sessions from a start date to an end date.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Prior Authorization Terminology

Concurrent Review

General (all payers)

Also called: continued stay review; concurrent authorization

Definition: A review during ongoing treatment that decides whether more sessions or days are authorized.
Why it matters: Missing a concurrent review can end authorization.
Illustrative example: A payer reviews an intensive outpatient program every set number of days.

Reference source URAC

Categories Prior Authorization Terminology

Gold Carding

General (all payers)

Also called: gold card program; authorization exemption

Definition: A payer program that exempts providers with a strong approval history from certain prior authorization requirements.
Why it matters: Reduces administrative burden where offered.
Illustrative example: A payer waives authorization for qualifying providers.

Verify: availability is payer- and state-specific.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Prior Authorization Terminology

Initial Authorization

General (all payers)

Also called: first authorization; initial approval

Definition: The first approval for a course of care, often for a limited number of units.
Why it matters: Followed by concurrent review for more units.
Illustrative example: A payer approves the first six sessions.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Prior Authorization Terminology

Level of Care

General (all payers)

Also called: LOC; outpatient level of care; IOP; PHP

Definition: The intensity and setting of treatment, from outpatient to intensive outpatient, partial hospitalization, residential, and inpatient.
Why it matters: Payers authorize by level of care using criteria.
Illustrative example: A payer approves intensive outpatient instead of partial hospitalization.

Reference source American Psychiatric Association

Categories Prior Authorization TerminologyBehavioral Health Specific Terms

Medical Necessity Criteria

General (all payers)

Also called: level of care criteria; InterQual; MCG; LOCUS; CALOCUS

Definition: The clinical guidelines payers use to judge medical necessity, such as proprietary criteria sets or level of care tools.
Why it matters: Knowing which criteria the payer uses helps shape documentation and appeals.
Illustrative example: A payer cites its level of care criteria in a denial letter.

Verify: criteria sets vary by payer.

Reference source American Psychiatric Association

Categories Prior Authorization TerminologyBehavioral Health Specific Terms

Peer Review

General (all payers)

Also called: clinical peer review

Definition: A review of a case by a clinician of similar specialty at the payer, often used in denials and appeals.
Why it matters: Shapes which clinician can speak to the payer.
Illustrative example: A psychiatric reviewer evaluates an appeal.

Reference source URAC

Categories Prior Authorization Terminology

Prior Authorization

General (all payers)

Also called: PA; prior auth; pre-authorization; precertification; preauthorization

Definition: A payer's approval, required before certain services, that the service meets its coverage and medical necessity criteria.
Why it matters: Services without required authorization are commonly denied and hard to recover.
Illustrative example: A payer requires prior authorization for psychological testing.

Verify: requirements are payer-, plan-, and code-specific.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Prior Authorization Terminology

Prior Authorization API

General (all payers)

Also called: CMS interoperability and prior authorization rule; electronic prior authorization

Definition: An electronic interface that lets systems exchange prior authorization requests and decisions, encouraged by CMS interoperability rules for certain payers over a phased timeline.
Why it matters: May reduce phone and fax steps over time.
Illustrative example: A payer exposes an API to check authorization requirements.

Time-sensitive: rule dates phase in; confirm the current timeline at cms.gov.

Reference source CMS (Centers for Medicare & Medicaid Services) · HL7 FHIR

Categories Prior Authorization TerminologyAI & Healthcare Automation Terms

Retro Authorization

General (all payers)

Also called: retroactive authorization; retro auth; after-the-fact authorization

Definition: A request for authorization after a service was delivered, allowed by some payers in limited circumstances.
Why it matters: Not universally accepted, so it is not a plan to rely on.
Illustrative example: A payer accepts a retro authorization request within a short window after an urgent service.

Verify: payer-specific.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Prior Authorization Terminology

Retrospective Review

General (all payers)

Also called: retro review; post-service review

Definition: A review done after care is delivered to decide coverage or medical necessity.
Why it matters: Can lead to denials for services already delivered.
Illustrative example: A payer reviews notes after a claim is submitted.

Reference source URAC

Categories Prior Authorization TerminologyAudits & Compliance

Step Therapy

General (all payers)

Also called: fail first; step therapy protocol; medication step edit

Definition: Step therapy is a payer rule that requires a patient to try one or more preferred drugs before the plan covers another drug.
Why it matters: It affects psychiatric prescribing. Prescribers may request an exception with documentation of medical need.
Illustrative example: A plan denies a newer antidepressant until the patient has tried two generics, and the psychiatrist files an exception request.

Verify: Rules vary by plan.

Reference source American Psychiatric Association

Categories Prior Authorization TerminologyBehavioral Health Specific Terms

Utilization Review (UR)

General (all payers)

Also called: UR; utilization management; UM

Definition: A payer process that evaluates whether requested or delivered care is medically necessary and appropriate.
Why it matters: UR drives authorizations, concurrent review, and many behavioral health denials.
Illustrative example: A payer's UR nurse reviews a request for additional sessions.

Reference source URAC

Categories Prior Authorization TerminologyAudits & Compliance

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Prior Authorization Terms: Definitions for Therapists and Psychiatrists

In this section

Authorization Date Range

Authorization Number

Authorization Request

Authorized Units

Concurrent Review

Gold Carding

Initial Authorization

Level of Care

Medical Necessity Criteria

Peer Review

Prior Authorization

Prior Authorization API

Retro Authorization

Retrospective Review

Step Therapy

Utilization Review (UR)

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CPT & E/M Code Guide

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