Understanding Prior Authorization in Health Insurance

If you have ever been told by your doctor's office that they need to "get authorization" before a procedure, test, or medication, you have encountered prior authorization. Also known as pre-authorization or pre-certification, this process is one of the most common — and often most frustrating — aspects of health insurance. Understanding how it works can help you avoid unexpected delays and denials.

What Is Prior Authorization?

Prior authorization is a requirement by your health insurance company that your healthcare provider obtain approval before delivering a specific service, procedure, or medication. The insurer reviews the request to determine whether the proposed treatment is medically necessary and covered under your plan. If prior authorization is required and not obtained, your insurance company may refuse to pay for the service — leaving you responsible for the full cost.

Common services that frequently require prior authorization include:

• Advanced imaging such as MRIs, CT scans, and PET scans
• Specialty medications, particularly high-cost or biologic drugs
• Elective or non-emergency surgeries
• Durable medical equipment like wheelchairs, CPAP machines, or prosthetics
• Inpatient hospital stays and rehabilitation services
• Mental health and substance abuse treatment beyond initial visits

How the Prior Authorization Process Works

Typically, your healthcare provider initiates the prior authorization request by submitting clinical documentation to your insurance company that supports the medical necessity of the proposed treatment. The insurer's utilization review team then evaluates the request against their coverage criteria. Decisions are usually made within a few business days for standard requests, though urgent requests may be expedited. You or your provider will be notified of the decision in writing.

What to Do If Your Prior Authorization Is Denied

A denial does not have to be the final answer. You have the right to appeal any prior authorization denial. Start by asking your insurer for the specific reason the request was denied. Your doctor can often submit additional documentation or a peer-to-peer review to provide further justification. If the internal appeal is unsuccessful, you may be entitled to an external review by an independent third party. Keep detailed records of all communications and deadlines throughout the process.

Prior authorization can be a complex and time-consuming process, but you do not have to navigate it alone. Resilience Health Advisors can help you understand your plan's prior authorization requirements and advocate for the coverage you deserve. Contact us today if you need help with a prior authorization issue or want to choose a plan with fewer administrative hurdles.