Prior Authorization Basics

What is Prior Authorization?

Prior authorization (also called pre-authorization, pre-approval, or pre-certification) is insurance company approval required before certain services, procedures, or medications are covered.

Why Prior Authorization Exists

From the Insurer's Perspective

• Ensures medical necessity
• Controls costs
• Prevents inappropriate care
• Confirms coverage applies

The Reality

Prior auth is controversial because:

• It can delay necessary care
• Creates administrative burden
• Sometimes results in inappropriate denials
• Requires significant time and effort

What Typically Requires Prior Authorization

Common Services

• Elective surgeries
• Advanced imaging (MRI, CT, PET scans)
• Physical therapy (after initial visits)
• Mental health services
• Durable medical equipment
• Home health services
• Specialist referrals (some plans)

Medications

• Brand-name when generic exists
• Specialty drugs
• High-cost medications
• Drugs with abuse potential
• Certain dosages or quantities

Hospital Services

• Non-emergency admissions
• Extended stays
• Rehabilitation services
• Skilled nursing facility care

Check Your Plan

Every plan is different. Review your:

• Summary of Benefits
• Evidence of Coverage
• Insurance website
• Member services hotline

How to Get Prior Authorization

Who Requests It

Usually your healthcare provider, but you should:

• Confirm they're requesting it
• Provide insurance information accurately
• Follow up to ensure it's submitted

The Process

1. Provider determines service is needed
2. Provider submits request to insurance
3. Insurance reviews request
4. Insurance makes decision
5. Both you and provider are notified

What's Submitted

Prior auth requests include:

• Patient information
• Diagnosis codes
• Proposed service/procedure codes
• Medical records supporting necessity
• Treatment history

Timeline

• Standard requests: 15 days for decision
• Urgent requests: 72 hours
• Prescription drugs: 72 hours (24 hours if urgent)

Getting Approval

Tips for Success

• Ensure accurate, complete information
• Include all supporting documentation
• Follow up on pending requests
• Ask about expedited review if urgent

If Approved

• Note the authorization number
• Understand what's authorized (specific services, dates)
• Know any conditions or limitations
• Confirm validity period

If Denied

You can:

• Request peer-to-peer review
• File an appeal
• Ask provider for alternative approach
• Request expedited appeal if urgent

What Happens Without Authorization

If You Proceed Without It

Risk of:

• Claim denial
• Full financial responsibility
• No insurance coverage applied
• Balance billing from provider

Exceptions

Prior auth may not be required for:

• Emergency services
• Urgent care in some situations
• Routine preventive care
• Follow-up for authorized services

Retroactive Authorization

Sometimes possible after the fact:

• For emergencies
• When delay would harm patient
• If provider can justify oversight
• Depends on insurance policy

Common Problems

Delays

Prior auth takes time:

• Submit requests early
• Follow up regularly
• Request expedited review when appropriate

Denials

Common denial reasons:

• Not medically necessary
• Alternative treatment required first
• Missing documentation
• Service not covered

Expiration

Authorizations have end dates:

• Note the validity period
• Schedule service within timeframe
• Request extension if needed

Your Rights

Regarding Prior Auth

You have the right to:

• Know what requires authorization
• Receive timely decisions
• Appeal denials
• Request expedited review for urgent needs
• Receive written explanation of denials

Federal Protections

• Emergency care cannot be denied for lack of prior auth
• Mental health parity requires equivalent auth requirements
• ACA plans have appeal rights

Tips for Managing Prior Auth

Be Proactive

• Ask if prior auth is needed before scheduling
• Confirm provider has submitted request
• Get authorization number before procedure

Document Everything

• Keep copies of authorization
• Note authorization numbers
• Save confirmation communications
• Record phone call details

Follow Up

• Check status if not notified
• Don't assume approval
• Get written confirmation
• Verify before service date

Prior authorization is a hurdle, but understanding the process helps you navigate it successfully.