Prior Authorization

Prior authorization (also called pre-authorization, pre-certification, or just “prior auth” / PA) is approval from your health insurance plan before a specific medical procedure, medication, or test is performed. Without prior authorization when required, the plan may refuse to pay — leaving you with the full bill even if the service is otherwise covered.

What requires prior authorization?

Common services that may require prior authorization:

• Advanced imaging — MRI, CT scan, PET scan
• Specialty drugs — Cancer drugs, biologics, expensive specialty medications
• Brand-name drugs when a generic exists (step therapy may be required first)
• Elective surgery — Joint replacement, bariatric surgery, plastic procedures
• Inpatient hospital stays that are not emergencies
• Skilled nursing facility care
• Durable medical equipment — wheelchairs, oxygen, CPAP machines
• Certain mental health and substance abuse treatments
• Some physical therapy beyond a certain number of visits

Each plan has its own prior authorization list. Check the plan’s website or call member services to verify before scheduling.

How prior authorization works

1. Your doctor decides you need a procedure, drug, or test that requires prior auth.
2. The doctor’s office (or the pharmacy, for drugs) submits a prior authorization request to the insurer, including clinical documentation.
3. The insurer reviews — typically takes 1-14 days, sometimes faster for urgent requests.
4. The insurer approves, denies, or asks for more information.
5. If approved, you can proceed.
6. If denied, you can appeal.

Why insurers require prior authorization

The stated reason is to ensure medical necessity and cost control — making sure the procedure or drug is appropriate for your condition and that less expensive alternatives have been tried.

The criticism: prior authorization adds delay, paperwork, and frustration. It can delay critical care. Many medical specialty groups have called for reform.

Some states (and federal proposals) have moved to require faster turnaround and electronic prior authorization to reduce delays.

What if prior authorization is denied?

You have the right to appeal:

1. Internal appeal — Submit additional documentation to the insurer arguing medical necessity.
2. External (independent) review — If the internal appeal fails, you can request an independent third-party review. The decision is binding on the insurer.
3. State insurance regulator — File a complaint with your state’s insurance department.
4. Federal court — In severe cases, plan beneficiaries can sue.

Your doctor’s office often handles the appeal on your behalf. The Patient Advocate Foundation and similar nonprofits help when needed.

Step therapy

A common form of prior authorization is step therapy — the plan requires you to try a cheaper drug first before approving a more expensive one. If the cheaper drug does not work or causes side effects, you can move to the next “step.” Some states have step therapy reform laws that allow exceptions when medically warranted.

Urgent vs. standard prior authorization

• Urgent (expedited): Typically a 24-72 hour turnaround when delay could cause harm.
• Standard: Typically up to 14 calendar days.

If your doctor flags a request as urgent, the insurer must follow expedited timelines.

Related terms

• Referral
• Formulary
• Network

Get help understanding plan rules — a licensed agent can pull prior authorization requirements for each plan in your zip code.