What is the process called that determines whether a particular medical treatment will be covered under a patient's insurance policy?

The process that determines whether a particular medical treatment will be covered under a patient's insurance policy is referred to as pre-certification. This process involves obtaining approval from the insurance provider before the treatment is provided to ensure that the procedure meets the insurer's guidelines for coverage.

Pre-certification often requires the healthcare provider to submit detailed information about the proposed treatment, explaining its necessity and appropriateness for the patient's condition. The insurance company then reviews this information to decide whether to authorize the procedure based on the policy terms and the medical necessity of the treatment.

While prior approval may seem similar, it is typically a broader term that can encompass various types of permissions required before service delivery, not limited to medical treatment. Claims processing refers to how insurance claims are handled after services have been rendered, and policy verification is a more general term that can involve checking if a patient's coverage is active, rather than specifically determining the coverage eligibility of a treatment.