What must usually be received from a payer before treatment by a specialist will be covered?

Prior approval, also known as precertification or preauthorization, is typically required by many insurance payers before a specialist can provide treatment that will be covered under a patient’s insurance plan. This process involves obtaining permission from the insurance company, ensuring that the proposed treatment is deemed medically necessary and meets the payer's guidelines for coverage.

The need for prior approval helps to control costs and ensure that both the provider and the patient are aligned with the payer's requirements before treatment is rendered. Without this approval, the payer may deny the claim for services rendered by the specialist.

In contrast, remittance advice is a document sent to providers after a claim has been processed, detailing the payment received and any adjustments made but does not pertain to pre-treatment authorization. Sanction generally involves disciplinary actions in a professional context and is unrelated to patient care. Explanation of benefits, while important, is a summary provided to patients after a claim is processed, explaining what was covered and what the patient may owe, rather than being a requirement before treatment begins.