What Is Prior Authorization?
Prior authorization (also called pre-authorization, pre-approval, or prior auth) is a requirement from your health insurance company that certain medical services or medications must be approved before you receive them. If you skip this step when it's required, your insurer can deny coverage.
โ ๏ธ Prior authorization is not a guarantee of coverage or payment. Even with prior auth, your claim can still be denied if the service is deemed not medically necessary after the fact.
What Commonly Requires Prior Authorization
- Non-emergency surgeries and procedures
- MRIs, CT scans, PET scans
- Brand-name and specialty prescription drugs
- Mental health and substance use treatment
- Durable medical equipment (wheelchairs, CPAP machines)
- Specialist referrals (in some HMO plans)
- Inpatient hospital admissions (for non-emergencies)
- Home health care
How Prior Authorization Works
- Your doctor determines you need a service or medication
- Your doctor's office submits a prior authorization request to your insurer with clinical documentation
- Your insurer reviews the request โ typically takes 3โ15 business days (1โ3 days for urgent requests)
- Approval or denial is issued โ if denied, you have the right to appeal
What to Do If Prior Auth Is Denied
- Request a peer-to-peer review โ your doctor speaks directly with the insurer's medical reviewer
- File a formal appeal โ you have the right to appeal any denial
- Request an expedited appeal if the situation is urgent
- Contact your state's insurance commissioner if internal appeals fail
Calculate Your Out-of-Pocket Cost
See what you'd owe if a claim is denied or approved with our cost calculator.
Calculate Your Out-of-Pocket Cost โFrequently Asked Questions
How long does prior authorization take?
Standard prior authorization typically takes 3โ15 business days. Urgent or expedited requests must be processed within 72 hours. Emergency care does not require prior authorization.
Can I appeal a prior authorization denial?
Yes. You have the right to appeal any prior authorization denial. First file an internal appeal with your insurer. If that fails, you can request an external review by an independent organization. Your insurer must tell you how to appeal in their denial letter.
What happens if I don't get prior authorization?
Your insurer can deny the claim entirely, leaving you responsible for the full cost. Some insurers may process the claim at a reduced rate. Always check whether prior auth is required before scheduling non-emergency procedures.