Prior Authorization
Plain English
Prior authorization means getting your health plan's approval before certain care, such as an MRI, a surgery or an expensive prescription. Your doctor's office usually asks for it. If you skip it when your plan requires it, the plan may not pay, even for care it would normally cover. You can appeal a denial.
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Definition
Prior authorization, also called preauthorization or precertification, is approval from a health plan that may be required before a member gets a service or fills a prescription, in order for it to be covered. Plans commonly require it for certain surgeries, imaging, specialty drugs and hospital stays. Without it, the plan may refuse to pay even for a service it would otherwise cover.
Why It Matters
A missing prior authorization is a common reason for a surprise bill. Checking before a planned procedure, and getting the approval number in writing, protects you. If the plan denies the request, you generally have a right to appeal.
Real-World Example
Imagine a doctor orders an MRI of a knee. The plan requires prior authorization for MRIs, and the imaging center assumes the doctor's office sent the request, but it didn't. The plan denies the claim. If the patient had called the plan beforehand, they'd have found out approval was needed. Now they ask the doctor's office to request it after the fact and, if the plan still says no, file an appeal.
Common Misconceptions
- Prior authorization guarantees payment. It means the plan approved the service; deductibles, coinsurance and plan terms still apply.
- The patient has to request it. The doctor's office usually does, but it's worth checking it was done.
- A denial is final. Plans have an internal appeal process, and many denials can also get an external review.
Key Takeaways
- HealthCare.gov: prior authorization is "approval from a health plan that may be required before you get a service or fill a prescription."
- It's commonly needed for some surgeries, imaging, specialty drugs and hospital stays.
- Ask the plan or the doctor's office whether it's needed, and keep the approval number.
- A denied request can be appealed.
Frequently Asked Questions
What is prior authorization?
Approval from your health plan that may be needed before you get certain care or fill a prescription, for the plan to cover it.
Who requests prior authorization?
Usually your doctor or the provider's office. Ask them to confirm it was approved before the service.
What happens if I don't get prior authorization?
The plan may deny the claim, leaving you to pay. Ask the provider to request it after the fact if the plan allows, and appeal if denied.
Can I appeal a prior authorization denial?
Generally yes. Plans have an internal appeal process, and you may be able to ask for an external review by an independent reviewer.
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The factual claims on this page were checked against these sources. Rules and figures change, so check the source itself if you need to confirm the current version.
- healthcare.govPrior authorization - Glossary · HealthCare.gov (U.S. Centers for Medicare & Medicaid Services)
- healthcare.govAppealing a health plan decision · HealthCare.gov (U.S. Centers for Medicare & Medicaid Services)
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