What Does Getting Prior Authorization Mean?
Getting prior authorization means receiving approval from a health plan before a medication, diagnostic test, procedure, therapy, or other covered service is provided when the plan requires it. The healthcare provider typically submits clinical information to the insurer, which reviews the request against the patient’s benefits and medical-necessity criteria before approving, denying, or requesting more information.
HealthCare.gov describes prior authorization as approval from a health plan that may be required before a person receives a service or fills a prescription so the service or prescription can be covered by the plan.
Prior authorization may also be called preauthorization, preapproval, or precertification. The exact terminology, requirements, documentation, and decision process can vary by health plan.
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What Happens During a Prior Authorization Request?
A prior authorization request gives the health plan information it needs to decide whether a requested medication, procedure, test, therapy, or other service meets its coverage requirements.
A typical request moves through these stages:
A typical request moves through these stages:
- The healthcare practice checks the patient’s insurance coverage and whether prior authorization is required.
- The provider or authorized staff gathers the documentation requested by the payer.
- The request is submitted through the payer’s required portal, form, electronic workflow, fax, or other approved channel.
- The health plan reviews the request against its coverage requirements.
- The payer approves the request, denies it, or asks for additional information.
- The practice records the decision and follows the appropriate next action.
Clinical decisions and medical-necessity determinations remain with the healthcare provider and health plan. Administrative staff can support documentation, submission, tracking, and payer follow-up.
For a closer look at payer coordination, visit Portiva’s page about the prior authorization process.
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Who Usually Sends the Prior Authorization Request?
The healthcare provider or an authorized member of the provider’s staff usually initiates the request when the patient’s health plan requires prior approval.
The patient may need to provide insurance information or communicate with the practice and health plan, but the clinical documentation generally comes from the treating provider. The insurance company then reviews the submitted material and makes the coverage decision.
Practices should confirm each payer’s requirements because submission procedures differ among commercial insurers, Medicare-related plans, Medicaid programs, pharmacy benefit managers, and other health plans.
How Long Can a Prior Authorization Decision Take?
Prior authorization timing depends on the health plan, the type of request, whether the request is urgent, and whether all required documentation was included.
For certain payers affected by current Centers for Medicare & Medicaid Services requirements, decisions for medical items and services must generally be sent within 72 hours for expedited requests and seven calendar days for standard requests. These federal requirements do not apply in the same way to every health plan, and the cited CMS rule excludes prescription drugs from these particular timeframes.
Missing documentation, incorrect insurance information, an incomplete clinical record, or a request for additional information can also affect the process.
Medication authorization timing may follow different requirements. Portiva covers that subject separately in its article about prior authorization timing for medication.
Which Medications and Services May Need Prior Authorization?
Prior authorization requirements vary by plan. A treatment that requires approval under one plan may not require it under another.
| Category | Examples that may require prior authorization |
|---|---|
| Prescription drugs | Specialty medications, high-cost drugs, medications with formulary restrictions, or drugs subject to utilization-management rules |
| Diagnostic imaging | MRI, CT, or PET imaging under certain plans |
| Procedures | Certain elective or scheduled procedures |
| Therapies | Physical, occupational, behavioral, or specialty therapies depending on coverage |
| Medical equipment | Certain durable medical equipment or supplies |
| Specialty care | Selected treatments or services subject to payer-specific requirements |
Patients and practices should verify the specific plan rather than assuming that approval is always required.
Does Emergency Care Require Prior Authorization?
A person who needs emergency medical care should not delay seeking treatment in order to complete a routine prior authorization request.
Coverage, notification requirements, post-service review, and related insurance procedures can depend on the health plan and applicable program rules. Patients should review their insurance information or contact the health plan when questions arise after emergency care has been provided.
Why Do Health Plans Require Prior Authorization?
Health plans use prior authorization to review whether certain requested services or medications meet their coverage requirements before they are provided or dispensed.
Depending on the plan and request, the review may examine medical necessity, coverage criteria, formulary requirements, treatment alternatives, quantity limits, site-of-care requirements, or other utilization-management rules.
Prior authorization is therefore a coverage review process. It should not be presented as a guarantee that every related charge will ultimately be paid.
What Commonly Delays a Prior Authorization Request?
Incomplete or inconsistent information is one of the most avoidable sources of administrative delay.
Practices can reduce preventable back-and-forth by checking the patient’s active coverage, confirming that authorization is required, reviewing the payer’s current documentation requirements, gathering supporting records before submission, recording the payer reference number, and tracking the request until a decision is received.
If a request is denied, the denial reason should be reviewed before a resubmission or appeal is prepared. Portiva covers that subject in more detail on its page about appealing a prior authorization denial.
── WHO'S BEHIND THIS
Provider Profile
Sanju Zachariah
Founder & CEO, Portiva
Sanju Zachariah is the Founder and CEO of Portiva, a healthcare staffing company he established in 2009 to help medical practices reduce administrative burdens and operate more efficiently. Before founding Portiva, Sanju worked as a management consultant at Accenture and PwC, where he gained extensive experience in process improvement and operational strategy.
Inspired by firsthand frustrations with inefficiencies in healthcare administration, he built Portiva to provide scalable virtual support that allows healthcare professionals and business leaders to focus on higher-value work.
2009
3
US
Frequently Asked Questions:
Is prior authorization the same as a referral?
No. A referral generally directs a patient from one healthcare provider to another, while prior authorization is a health plan’s review of a medication, service, procedure, test, or treatment before coverage is confirmed under the plan’s rules.
Portiva explains the distinction further in its article about referrals and prior authorization.
Does prior authorization mean the insurance company will definitely pay?
Not necessarily. Prior authorization means the payer has reviewed the request under its applicable authorization requirements. Other coverage, eligibility, coding, billing, or plan conditions may still affect final claim payment.
Can a prior authorization request be denied?
Can prior authorization be required for prescriptions?
Can administrative staff support prior authorization?
- How is prior authorization applied in pharmacy policies?
- How is an appeal for a denied prior authorization conducted?
- How is prior authorization applied in insurance policies?
- How is prior authorization applied in the context of prescribing medication?
- Does the policy of Medicare on surgery include requiring prior authorization?
- How is prior authorization applied in Medicaid’s operations?
- How can documentation be optimized to speed up medication prior authorization?
- Do Medicare policies stipulate prior authorization for particular healthcare needs?
- What are the best practices for healthcare providers in securing prior authorization for medication?
- Can follow-ups with insurance providers reduce the prior authorization time for medication?
- What are the best practices for healthcare providers when dealing with Prime Therapeutics’ prior authorization form?
- What role do patient advocacy groups play in addressing the challenges of medication prior authorization?
- How is an appeal for a denied prior authorization conducted?
- How does the appeals process work for Medicare prior authorization denials?
- What strategies can healthcare systems implement to reduce the burden of medical prior authorization?
- How does the appeals process work for prior authorization denials at Express Scripts?
- How does technology influence the efficiency of obtaining prior authorization?
- How does the scope of medical services covered by referrals compare to that of prior authorizations?
- What strategies can healthcare systems implement to reduce the burden of insurance prior authorization?
- How do healthcare providers coordinate with insurance companies during the prior authorization process?
- What role does patient advocacy play in addressing issues with prior authorization in healthcare?
- Can the outcome of a prior authorization request for a prescription be appealed, and how?
- What role do patient advocacy groups play in reforming prior authorization practices?
- How do prior authorization nurses advocate for patients in the authorization process?
- What distinguishes prior authorization pharmacists from other pharmacy specialties?
- How do remote prior authorization specialists advocate for patient needs in the authorization process?
- How do prior authorization specialists advocate for patients during the authorization process?
- How are urgent medication needs handled within the prior authorization framework?
- What preventive measures can be taken to minimize the risk of preauthorization or precertification denial?
