Prior authorization is a health plan’s review process for deciding whether a requested service, medicine, device, or treatment meets the plan’s coverage rules before the plan agrees to pay for it. The exact requirements, deadlines, forms, and appeal rights vary by payer and plan. For federal program information, review CMS.gov and Medicaid.gov, then confirm the details directly with the health plan.
Prior authorization is often called “prior approval,” “preauthorization,” or “precertification.” Despite the different names, the basic idea is similar: the insurer wants information before a service occurs or a prescription is filled. That information may help the plan determine whether the request is covered, medically necessary under its rules, appropriate for the member’s condition, and eligible for payment.
A prior authorization is not the same as a guarantee that the plan will pay. Approval usually means the request met the plan’s stated criteria at the time of review. Other issues can still affect payment, including eligibility on the date of service, network status, coding, benefit limits, deductibles, coinsurance, and whether the provider follows the approval’s terms.
What does prior authorization mean?
Prior authorization means a payer reviews a proposed healthcare service before the service is provided or a medication is dispensed. The payer may ask the treating clinician for records, test results, a diagnosis, previous treatment history, or a reason that a particular option is needed.
The review is intended to apply the plan’s coverage policies. For example, a plan may require authorization for certain advanced imaging studies, specialty drugs, inpatient admissions, procedures, durable medical equipment, or services delivered outside a routine benefit. Not every plan requires authorization for the same item.
The request commonly starts with the ordering clinician, facility, pharmacy, or equipment supplier. However, the member remains an important part of the process. You can ask what is being requested, who submitted it, whether the request is complete, and how to obtain the decision.
Why do health plans use prior authorization?
Health plans use prior authorization to manage benefits and apply coverage criteria before a cost is incurred. A review may assess whether a service is covered, whether it is supported by the information submitted, and whether another covered option must be tried first.
Some plans use authorization to coordinate care or direct members to particular settings and providers. A plan may also require documentation for services that are costly, specialized, limited by benefit rules, or vulnerable to billing errors. These purposes do not mean every decision is correct. They do mean that the plan’s written rules and the information submitted can affect the outcome.
Authorization is separate from the clinical judgment of the treating professional. A clinician may believe a treatment is appropriate, while the payer may decide that the request does not meet its coverage policy. That decision concerns payment under the plan. It does not necessarily determine whether the treatment is medically appropriate in every context.
Which services commonly need prior authorization?
Requirements vary, but prior authorization may apply to:
- Some advanced imaging services, such as certain scans.
- Inpatient hospital admissions or planned facility-based care.
- Specialty medications, biologic medicines, or high-cost prescriptions.
- Infusion services and some injectable treatments.
- Durable medical equipment and certain home health services.
- Planned surgeries, procedures, or therapies.
- Selected behavioral health, rehabilitation, or skilled care services.
- Care from an out-of-network provider, when the plan permits it.
This list is only a guide. A service that needs authorization under one plan may not need it under another plan, even when the plans use the same insurance company. Requirements may also differ based on the member’s employer group, state, product type, network, diagnosis, place of service, or the specific billing code.
Who is responsible for requesting prior authorization?
Responsibility commonly falls on the ordering provider, prescribing clinician, facility, pharmacy, or equipment supplier. The responsible party should submit the request through the payer’s required channel and provide the supporting information.
Members should not assume that a provider has completed the process simply because the provider recommended the service. Ask who will submit the request and request a reference number or confirmation when available. You can also ask whether the authorization is required before scheduling, treatment, delivery, or dispensing.
Some plans place responsibility on the member in particular circumstances, especially when the member chooses an out-of-network provider or seeks services without a referral. Read the plan materials and call the member services number on the insurance card. Ask the representative to explain the requirement for your exact plan and service.
What information does a prior authorization request include?
A request may include the member’s identifying information, the provider’s details, the requested service or medication, diagnosis information, procedure or drug codes, and the proposed date or duration of treatment. The payer may also request clinical notes, imaging reports, laboratory results, treatment history, and documentation of symptoms or functional limitations.
For a medication, the plan may ask about the diagnosis, dosage, prior medicines, response to treatment, side effects, contraindications, or why a preferred alternative is not suitable. For a procedure, it may ask for examination findings, prior conservative care, test results, or the reason the procedure is needed now.
The quality and completeness of the submission matter. Missing pages, unclear dates, incorrect codes, or inconsistent clinical information can lead to a delay, a request for more information, or a denial. Ask the provider’s office whether the request was submitted completely and whether the payer requested anything else.
How long does prior authorization take?
There is no single processing time for every prior authorization. The timeframe can depend on the payer, plan, type of request, urgency, state requirements, completeness of the submission, and whether the service is for a prescription, outpatient care, or an admission.
Routine requests may take several business days or longer. Urgent requests may be reviewed more quickly when the plan’s rules recognize a risk of serious harm from waiting. The treating clinician generally must explain why a faster review is needed. An urgent label does not guarantee approval.
Ask the plan for its expected timeframe, the date the request was received, and the best way to check status. If a procedure or medication is time-sensitive, tell both the provider and the plan. Keep a record of names, dates, reference numbers, and instructions.
What happens after a request is submitted?
The payer may approve the request, deny it, approve it with limits, or ask for more information. Some requests may be reviewed by clinical staff, while others may be referred for a physician or other qualified clinical review under the plan’s procedures.
An approval notice may identify the authorized service, provider or facility, number of visits or units, medication, effective dates, and authorization number. Read the notice carefully. Approval for one service does not automatically approve related services, follow-up care, a different provider, or a longer treatment period.
A request can also remain pending. “Pending” generally means the payer has not issued a final decision, not that the request has been approved. Ask what information is missing and whether the provider must respond by a particular date.
Does prior authorization guarantee payment?
No. Prior authorization is one coverage condition, not a promise to pay every claim. Payment can still depend on whether the member is covered on the date of service, whether the provider is in network, whether the service matches the approval, and whether the claim is submitted correctly.
Member cost sharing can also apply. The amount a person pays may include a deductible, copayment, or coinsurance, depending on the plan. Because plan designs differ, ask the health plan for a cost estimate based on the specific service, provider, facility, and coverage status. A provider’s estimate may not reflect the payer’s final claim determination.
Authorization may have an expiration date or a limit on visits, doses, units, or days. If treatment will continue beyond those limits, the provider may need to request a new authorization or an extension.
What is the difference between prior authorization and a referral?
A referral is generally a direction from one healthcare professional to another, often from a primary care clinician to a specialist. Prior authorization is a payer review of whether a service or item meets the plan’s coverage requirements.
A plan may require one, both, or neither. A referral does not necessarily satisfy a prior authorization requirement. Likewise, an approved prior authorization may not replace a required referral. Confirm both requirements before care is scheduled.
What is the difference between prior authorization and a medical necessity review?
Prior authorization is the process that occurs before a service or treatment under a plan’s rules. Medical necessity review is an assessment of whether the requested care meets the payer’s clinical coverage criteria. Medical necessity may be part of a prior authorization review, but the terms are not identical.
A payer may also conduct a retrospective review after care has been provided, depending on the plan and applicable requirements. That type of review can examine whether the service was eligible for payment even if an earlier authorization was issued.
What should you do if prior authorization is denied?
Read the denial notice first. It should explain the reason for the decision and describe available review or appeal options under the plan. Common reasons may include missing information, failure to meet a coverage criterion, use of a nonpreferred medicine, an excluded benefit, an expired authorization, or a request submitted after the required deadline.
Ask the provider to review the denial with you. The provider may identify an error, submit additional records, request a reconsideration, or recommend another covered option. Ask the plan whether the next step is a correction, peer-to-peer review, reconsideration, internal appeal, external review, or another process.
Do not ignore the deadline. Appeal periods can vary. Follow the instructions in the notice, keep copies of everything submitted, and request confirmation that the appeal was received. If the treatment is urgent, ask whether an expedited appeal is available.
Can you appeal a prior authorization denial?
Often, yes, but the exact process depends on the plan and the type of coverage. The denial notice should identify the applicable process, filing deadline, required documents, and address or submission method. A member, authorized representative, or provider may be able to file, depending on the plan’s rules.
An effective appeal usually addresses the reason for denial directly. Supporting material may include updated clinical notes, test results, medical history, prior treatment results, relevant safety concerns, and an explanation from the treating clinician. The appeal should clearly state what service or medicine is requested and why the submitted information satisfies the plan’s criteria.
For information about federal health programs and general program resources, consult CMS.gov. For Medicaid-related information, consult Medicaid.gov. These resources do not replace the instructions in your plan’s denial letter or the requirements of your state program.
What should you ask the health plan?
When calling the plan, ask focused questions and write down the answers. Useful questions include:
- Does this exact service, medication, device, or procedure require prior authorization?
- Is authorization required for this provider, facility, pharmacy, or place of service?
- Who must submit the request?
- What documents and codes are required?
- Has the request been received, and what is its reference number?
- What is the routine processing timeframe?
- Can the request receive an urgent review?
- What are the authorized dates, units, visits, or doses?
- Does the approval apply to the provider and facility I plan to use?
- What member costs may apply?
- What happens if the request is denied?
- What is the appeal deadline?
Ask the representative to repeat unfamiliar terms and explain whether the answer is based on your current plan. Record the date, representative’s name or identification number if provided, reference number, and any promised follow-up.
How can you avoid common prior authorization problems?
Start by checking the requirement before scheduling care, filling a new prescription, or purchasing equipment. Use the member services number on your current insurance card rather than relying only on information from an older plan year or a general website.
Make sure the provider has your current insurance information and that the request identifies the correct plan. Ask for an early submission when a service is planned. Follow up if the request is pending, and ask whether the payer needs additional records.
Do not assume that an authorization transfers when you change plans, providers, pharmacies, facilities, or medications. A change in dosage, treatment location, billing code, or authorization period may require a new review. Confirm locally with the plan and the treating provider before proceeding.
What if care is urgent or an emergency?
Prior authorization rules for emergencies and urgent care may differ from rules for planned services. Do not delay emergency medical attention while trying to obtain approval. Seek emergency care when appropriate and ask the facility or plan about notification requirements afterward.
For urgent but nonemergency care, tell the clinician and payer why waiting could create a serious health risk. Ask whether the plan has an expedited process and what documentation is needed. The plan’s definition of urgent care and its notification rules control the process for that coverage.
What is the main takeaway about prior authorization?
Prior authorization is a payer review before certain care is provided or certain medicine is dispensed. It can affect whether a plan will cover the request, but approval is not an unconditional payment guarantee. Requirements, deadlines, clinical criteria, appeal rights, and member costs vary by payer and plan.
Before receiving planned care, confirm the requirement with the plan, make sure the provider submits complete information, obtain the decision in writing when possible, and check the authorization’s limits and expiration date. If the plan denies the request, review the notice promptly and use the stated appeal process. Always confirm current details locally because the plan governing your coverage is the final source for its authorization rules.