The clinical standards a payer uses to determine whether a requested service or medication is appropriate and required for a patient's condition.
What it means
These criteria vary by payer and change frequently, which is one of the biggest sources of friction in prior authorization — a request that clears one payer's criteria may not clear another's, even for the same clinical scenario. Automation that stays current on these criteria in real time avoids submissions that fail simply because the underlying rules shifted.
