Prior Authorization: What It Is and How to Get Approval
Prior authorization is insurance approval required before certain treatments. Learn how to navigate the process, avoid denials, and appeal if needed.
What Is Prior Authorization?
Prior authorization (also called preauthorization, prior approval, or precertification) is a requirement by your health insurance company that your doctor obtain approval before providing certain treatments, medications, or services. The insurance company reviews whether the proposed care is medically necessary and covered under your plan before agreeing to pay for it. Without prior authorization when required, your claim may be denied entirely.
Services That Commonly Require Prior Authorization
Insurance companies require prior authorization for services that are expensive, have potential for overuse, or have cheaper alternatives. The specific requirements vary by plan, but common categories include:
- Advanced imaging (MRI, CT scan, PET scan)
- Specialty medications and biologics
- Elective surgeries and inpatient procedures
- Durable medical equipment (wheelchairs, CPAP machines)
- Mental health and substance abuse treatment
- Physical therapy beyond initial visits
- Home health care services
- Genetic testing
- Cancer treatments and chemotherapy
- Specialty referrals in HMO plans
The Prior Authorization Process
Your healthcare provider typically initiates the prior authorization process by submitting a request to your insurance company. This request includes your diagnosis, the proposed treatment, clinical documentation supporting medical necessity, and any prior treatments you've tried. The insurance company reviews this against their coverage criteria and either approves, denies, or requests additional information.
Timeline: How Long Does Prior Authorization Take?
Standard prior authorization requests typically take 5-14 business days, though this varies by insurer and state regulations. Urgent or expedited requests must be processed faster—usually within 24-72 hours for medical services and 24 hours for prescription drugs. Medicare Advantage plans must respond within 72 hours for standard requests and 24 hours for expedited requests.
- Standard requests: 5-14 business days
- Urgent requests: 24-72 hours
- Prescription drugs (standard): 72 hours
- Prescription drugs (urgent): 24 hours
- Medicare Advantage: 72 hours standard, 24 hours expedited
What Happens If Prior Authorization Is Denied?
If your prior authorization is denied, you have the right to appeal. The denial letter must explain the reason and your appeal rights. Common denial reasons include: the service isn't covered, it's not medically necessary according to their criteria, or there's insufficient documentation. Many denials can be overturned on appeal when additional clinical information is provided.
Prior Authorization vs. Predetermination
Prior authorization and predetermination serve different purposes. Prior authorization is required approval—without it, your claim may be completely denied. A predetermination is a cost estimate that tells you what insurance will pay but doesn't guarantee coverage. Some procedures require both: prior authorization for approval and a predetermination to understand your out-of-pocket costs.
How to Get Prior Authorization Approved
Verify if prior authorization is required
Before scheduling treatment, check with your insurance company whether prior authorization is needed. Your provider's office can also check, but confirming yourself ensures nothing is missed.
Gather supporting documentation
Work with your doctor to compile thorough documentation including diagnosis codes, clinical notes, lab results, imaging studies, and records of any prior treatments that failed.
Submit a complete request
Ensure your provider submits all required forms and documentation. Incomplete submissions are a leading cause of delays and denials. Ask for a copy of what was submitted.
Follow up proactively
Call your insurance company 2-3 days after submission to confirm receipt. If additional information is requested, respond quickly. Get a reference number and document all interactions.
Appeal denials with additional evidence
If denied, request a peer-to-peer review where your doctor speaks directly with the insurance company's medical director. Submit additional documentation and consider citing relevant medical guidelines.
Frequently Asked Questions
What is prior authorization?
Prior authorization is approval from your health insurance company that must be obtained before receiving certain treatments, medications, or services. It confirms the care is medically necessary and covered under your plan.
What happens if I don't get prior authorization?
If prior authorization is required but not obtained, your insurance company may deny the claim entirely, leaving you responsible for the full cost. Some providers will check for you, but it's wise to verify yourself.
How long does prior authorization take?
Standard requests typically take 5-14 business days. Urgent or expedited requests must be processed within 24-72 hours. Ask your insurer about their specific timelines and request expedited review if medically necessary.
Can prior authorization be denied?
Yes. Denials happen when insurance determines a service isn't medically necessary, isn't covered by your plan, or when documentation is insufficient. You have the right to appeal any denial.
What's the difference between prior authorization and preauthorization?
They're the same thing. Prior authorization, preauthorization, prior approval, and precertification all refer to the requirement to get insurance approval before certain treatments.
How do I appeal a prior authorization denial?
Request a peer-to-peer review between your doctor and the insurance medical director. Submit additional clinical documentation supporting medical necessity. Follow your plan's formal appeal process, and consider an external review if internal appeals fail.
Prior Authorization Denied? We Can Help
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