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Understanding Prior Authorization Insurance: What You Need to Know

Unlock the understanding prior authorization insurance! Discover how it affects your medical care, why it’s important, and tips to navigate the process smoothly. Don’t let insurance hurdles catch you off guard—read on to stay informed and empowered!

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Understanding Prior Authorization Insurance: What You Need to Know

understanding prior authorization insurance with female VAIt can be difficult to understand the complexity of health insurance, particularly when trying to understand terminology like “prior authorization.” You’re not alone if you’ve ever pondered what this means and how it affects your access to healthcare.

To help you understand what prior authorization insurance is and how it may affect your ability to receive certain medical treatments and services, we’ll go into the topic in this piece.

What Is Prior Authorization?

The process your healthcare professional must go through to get clearance from your insurance company before recommending a specific drug, therapy, or service is called prior authorization, often known as pre-authorization or pre-approval. The goal of pre authorization is to ensure that your insurance provider’s recommended course of treatment is both legally and medically essential.
Your healthcare professional will submit a request outlining the suggested course of treatment and any supporting paperwork to your insurance company if they need advance authorization. After reviewing the request, the insurance provider will decide if the suggested course of action is both medically required and covered by your plan.

Why Do Insurance Companies Need Prior Authorization?

Prior authorization is a tool used by insurance companies to control costs and guarantee that the treatments they pay for are suitable and essential. Insurance companies are legally required to provide justification for particular treatments in order to prevent needless spending and advance evidence-based treatment. Although the goal of prior authorization is to provide patients with affordable, high-quality care, sometimes the procedure takes too long for both patients and medical professionals. Treatment delays and more documentation for medical staff are possible outcomes.

Which Treatment Types Need Prior Authorization?

understanding prior authorization insurance patient and the doctor

Your insurance plan and provider will determine which specific treatments and services need prior authorization. However, some common examples include:

  • Prescription drugs: Some prescription drugs, particularly those that are expensive or name-brand, may require prior authorization. Your physician must demonstrate that the medication is necessary and that less costly options are not suitable for your circumstances.
  • Specialized therapies: Some treatments may require prior clearance to ensure that they are medically necessary and fit your insurance plan’s coverage restrictions. These treatments involve genetic testing and certain surgical procedures, for instance.
  • Durable Medical Equipment: Your insurance company may want prior authorization to confirm that oxygen tanks, wheelchairs, or continuous positive airway pressure (CPAP) machines are necessary for your condition.
  • Hospital Stays: To make sure that inpatient care is appropriate and essential, your insurance carrier may occasionally need prior authorization for non-emergency hospital admissions.
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Mohammad Ashori, M.D.

Board Certified Family Medicine Physician

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Getting Around Prior Authorization

understanding prior authorization insurance elderly woman doctorIf you learn that a treatment or service requires prior authorization, you can facilitate the process by taking the following actions:

Work together with your healthcare provider: Your doctor will submit the prior authorization request on your behalf. You must be fully informed on the nature of the issue, the recommended course of action, and any necessary medical attention.
Keep your provider informed at all times, and supply them with any information needed to support the request.


  • Be proactive: If you are aware that a treatment or service you are seeking could need prior authorization, don’t wait until the last minute to contact someone. To prevent delays in your care, get started on the process as soon as you can.
  • Follow up: Make sure your insurance company has received the prior authorization request from your healthcare provider and inquire about its status once it has been submitted. If additional information is needed, promptly gather and submit the necessary documentation with your provider.
  • Know your rights: You can file an appeal if the decision denying your request for prior authorization is made. Work together with your insurance company and physician to understand the reasons behind the refusal and what steps you can take to challenge it. To bolster your case, you might need to present further proof or enlist the help of a patient advocate.

The Final Word

Knowing how prior authorization insurance operates is essential to ensure you can get the treatments and services you require, even if it can be a complicated and even irritating part of health insurance. Through tight collaboration with your healthcare provider, preemptive measures, and assertive advocacy, you can expedite and exude confidence during the prior authorization process.
Never forget that you should ask any queries you may have concerning preauthorization procedures or your insurance coverage to your medical team or your insurance company. Knowing the ins and outs of your insurance policy is essential if you want to take charge of your health and well-being since educated patients are empowered patients.

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