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What is a Prior Authorization for Insurance: Health Plans

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Discover with Portiva as we decode ‘What is a Prior Authorization for Insurance: Health Plans.’ Our aim is to simplify difficulties, prioritizing your well-being. Join us in grabbing the essentials of Prior Authorization, navigating insurance challenges effortlessly for your healthcare needs. Let’s empower you with knowledge and ensure a consistent healthcare journey.

Let’s jump into the details.

Table of Contents

prior authorization doctor prescribing patient a medication

Prior authorization for insurance means your health insurer reviews your request before they decide if a prescribed medication or treatment is medically necessary. They will approve your request if they believe it’s obligatory to cure your illness. However, if you don’t find it necessary, they may deny your prior approval request, and you’ll need to pay for your entire bill yourself.

This article will share key topics like prior insurance authorization, how the process works, why health insurance companies demand prior authorization, and how to obtain prior authorization approval for insurance.

How Prior Authorization Works?

For instance, you visit your healthcare provider for medical treatment, who prescribes a medical procedure to cure your illness. However, he needs to obtain approval from your health insurance provider before starting your treatment. Otherwise, your medical expenses won’t get covered.

Your healthcare provider sends a prior approval request and all necessary information to your health plan provider, who reviews your request for a specific medical procedure. Depending upon the clinical data and information the healthcare provider has shared with your health insurer, they decide whether to approve or refuse your prior approval request.

However, if your health insurer plan provider finds your request qualifies the plan guidelines, they’ll approve your request for a certain medical necessity. On the other hand, if it doesn’t meet the criteria, your health insurance company may accept your prior approval request.

Why Do Health Insurance Companies Ask For Prior Authorization?

The health plan provider requires prior authorization to review your request before approving the prescribed medication or medical procedure.

For instance, your healthcare provider may have prescribed a costly medication or medical treatment. Prior authorization helps your health insurance company to review your request and revert with their response. However, if they find a low-cost, effective alternative, they can recommend it for treating your medical state.

Who Is Responsible For Obtaining Prior Authorization?

health plans doctor writing on clipboard

The healthcare provider is mainly responsible for obtaining a prior authorization request. They start the process by sending a prior approval request alongside the patient’s necessary information to the insurance provider.

The health plan company assesses the request and shares its response based on the provided data. However, if they refuse your request, you can request them to review their decision.

How Much Time Prior Authorization Needed?

Your prior authorization request can take a week or maybe a month. If prescribed medication or medical procedure is complex, it can take several days; otherwise, it takes less time.

The information and the clinical data your healthcare provider submitted to your health insurer also play an essential role in the prior approval process of your request. Based on this information, your health insurance company reviews your request and reverts.

However, if shared information needs to be more accurate or complete in the request form, your prior authorization process will decelerate or possibly result in denial. To avoid rejection and ensure the process works at the right speed, it’s necessary that you carefully fill the request form with correct and thorough information and then submit it to your health insurance provider.

Medication & Medical Necessity That Require Prior Authorization

Several medications and procedures require prior approval before going forward with medical care. Following are some medications and medical treatments for which you need prior authorization.

Medication That Needs Prior Authorization

Prescription drugs with severe side effects.

Medication with a greater probability of addiction.

Prescription drugs are only used for cosmetic purposes.

Expensive medication.

Medication is used for specific health states.

Medical Necessity That Need Prior Authorization

Diagnostic imaging services like CT scans and MRI scans.

Medical treatments that are frequently abused.

Medical necessity is provided only in certain health conditions.

Non-emergency surgical services.

How can prior authorization benefit me?

Prior authorization helps the health insurance company review your request and decide if the medical service or medication is necessary. However, it can also benefit you in several ways. Following are some key benefits.

· Prevent prescribed medication or medical treatment that can be addictive or not medically necessary to cure your illness.

· Reduce medication or medical service costs by providing a low-cost, effective alternative.

· Prevent potentially threatening medication combinations.

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How To Obtain A Prior Authorization Approval

You must obtain approval from your health insurance company before taking the prescribed medication or medical treatment from your healthcare provider. If you fail to get prior approval, your health plan provider won’t pay for your medical expenses, and you’ll need to bear all the expenses on your own.

However, you must consider the following vital tips to help you obtain prior authorization approval.

Speak to the Decision-Maker

expensive treatments doctor explaining to a insurer

Your health insurance provider demands approval for a certain medical treatment or medication. However, it’s not certainly them who decides whether to approve your request or not. Many health insurers carry out in-house prior authorizations, while some get support from benefit management companies to review such requests.

Your health insurance company can consult a pharmacy benefits company to review your prior approval request. Similarly, your health plan provider may send your clinical data and all necessary information to on-field specialists to decide whether the prescribed medication or procedure is medically necessary. Based on their feedback, your health insurer will revert with their response. 

If you are still determining the decision-making person for your prior approval request, your health insurance company will guide you on the right path. However, don’t depend on your insurer to determine the approval or denial of your prior authorization request. Hold your words until you get a chance to speak to the decision-maker.

See the Clinical Guidelines

Read the clinical guidelines carefully as the reviewers decide on these rules. If you are still determining if these guidelines are available online, you can call your health plan provider to get the information. Also, if they are accessible online, your health insurer will send them to you.

Following these guidelines, you can submit the complete information your health insurance company requires to assess your request form.

Submit Accurate and Thorough Information

Share correct and detailed information with your health insurance provider to get approval. If anything needs to be updated or added to your form, your request will either get delayed or refused.

For instance, you wrote just your first name on your prior authorization form, which definitely won’t completely match the insurance company database. Because of this minor error, your health plan provider may deny your medication or medical procedure request.

Similarly, if the shared information needs to be completed or corrected, your prior approval request may result in denial. Thus, it’s essential to double-check your entire form after filling it out and then send it to your health insurance company for approval.

Call Your Health Insurer If They Reject Your Request

doctor taking a phone call

Contact your healthcare provider to determine why they refused your prior authorization request. Also, you can ask your healthcare provider why you rejected your request for a certain medication or medical necessity.

Ask your insurance provider to share the reason for denial in simple words. You may get approval if the rejection reason gets fixed.

For instance, your healthcare provider has prescribed a costly medication to cure your injury, which the health insurance company believes isn’t that medically necessary. Knowing this, you can ask your healthcare provider to strengthen your request by sharing a doctor’s statement. Your health insurer may approve your prior authorization request if it qualifies the health plan criteria.

Ensure Your Health Insurance Company Follows the Guidelines

Ensure your health insurer complies with the state regulations related to prior authorization.

For instance, your health plan provider can only demand a prior authorization request to decide if any medication or treatment is medically necessary if it has a similar protocol. Also, your insurance company can’t ask for prior authorization in an emergency case.

How to Fasten Up Prior Authorization Process

You can speed up your prior authorization process by contacting your health insurance company and sharing how vital this prescribed medication or medical treatment is for you. Also, you can prepare paperwork for all the correspondence between your healthcare provider and health insurer. However, to speed up your request, you must create a sense of urgency by regularly speaking to your healthcare provider and health insurance company.


The article provides a comprehensive understanding of prior authorization within health plans, accentuating their pivotal role in determining the approval or denial of prescribed medications and treatments. Health plans, mentioned throughout the narrative, serve as decision-makers. It is underscored that healthcare providers initiate the prior authorization process by submitting requests and patient information to health plans, which meticulously review the submitted data against established guidelines to decide the fate of requested medical procedures or medications. The significance of understanding and adhering to the clinical guidelines associated with health plans is emphasized, as submitting accurate and thorough information is crucial to avoiding potential delays or denials.

The repetitive mention of health plans reinforces their central role in insurance, requiring prior authorization to assess the necessity of costly treatments. The article also underscores the role of health plans in suggesting more cost-effective alternatives when available. Furthermore, it highlights the importance of ensuring that health plans adhere to state regulations related to prior authorization. Individuals are encouraged to proactively contact health plans if their prior authorization requests are denied and work collaboratively with healthcare providers to address the reasons behind the denial. The article intricately weaves the concept of health plans throughout, emphasizing their critical role in the prior authorization process and urging individuals to align with plan guidelines for successful approvals.

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