You’ve scheduled a procedure, gotten your prescription, or booked a specialist appointment—only to find out your insurance needs to approve it first. That frustrating step is called prior authorization, and it’s a growing part of the healthcare system. While insurers say it’s a way to control costs and prevent unnecessary care, it can also delay treatment and create confusion for patients. Here’s what prior authorization means, when it’s required, and how to deal with it so you can get the care you need without unnecessary setbacks.
What Is Prior Authorization?
Prior authorization (also called pre-approval or pre-certification) is when your health insurance provider requires you or your doctor to get approval before a medical service, test, or prescription drug is covered.
It’s most often used for:
Expensive medications or treatments
Specialist visits
Surgeries or outpatient procedures
Diagnostic tests (like MRIs or CT scans)
Certain durable medical equipment (DME)
Without this approval, your insurance may refuse to pay—leaving you with a large bill or delaying care until it’s resolved.
Why Do Insurance Companies Require It?
Insurance companies use prior authorization to:
Make sure the treatment is medically necessary
Encourage the use of lower-cost alternatives (like generic drugs)
Prevent overuse of expensive services
From their perspective, it helps manage healthcare costs and ensures appropriate care. But from the patient’s side, it can feel like an extra hurdle—especially when time-sensitive treatment is involved.
How Does the Prior Authorization Process Work?
Here’s a general overview of how the process typically goes:
Your provider recommends a service or prescription
The provider contacts your insurance company to request authorization
The insurance company reviews the request
You and your provider are notified if it’s approved, denied, or needs more information
Some insurers require you to submit paperwork or contact them directly, but usually, your provider’s office handles the request.
How Long Does It Take?
The timeline varies by insurer and urgency of care. It can take:
Within 24 hours for urgent care
3 to 5 business days for routine requests
Longer if additional documentation or reviews are needed
Delays can occur if:
Paperwork is incomplete or submitted late
The request is denied and needs an appeal
There’s back-and-forth between the insurer and provider
Common Services That Require Prior Authorization
Not all care needs pre-approval, but common examples include:
Brand-name or specialty drugs
Mental health or substance abuse treatment
Hospital admissions
Advanced imaging tests (MRI, PET, CT scans)
Elective surgeries
Certain physical, occupational, or speech therapies
Home health services or medical equipment
Each insurance company has its own list, so always check your plan documents or member portal to be sure.
What Happens If You Don’t Get Prior Authorization?
If you skip the prior authorization step:
The insurance company may deny the claim
You could be responsible for the full cost of the service
You might have to reschedule or delay your care
Always confirm with your provider that prior authorization has been obtained before proceeding with non-emergency care.
How to Check If You Need Prior Authorization
Log in to your insurance provider’s website or app
Search your plan’s coverage guidelines
Call the customer service number on your insurance card
Ask your doctor’s office to verify on your behalf
If you’re ever unsure, it’s better to double-check than to assume you’re covered.
What If Prior Authorization Is Denied?
It’s frustrating, but denials can be overturned. Here’s what to do:
Ask for the denial letter: It should explain why it was denied and what your options are.
Work with your provider: They can submit more documentation or challenge the denial.
File an appeal: Every insurer must offer an appeal process. You usually have a set window (e.g., 60 days) to respond.
Request an expedited review: If waiting would put your health at risk, ask for a faster review.
You also have the right to request an external review by an independent party if your insurer still denies the request.
How to Make the Process Easier
Keep records: Track all calls, emails, and letters related to the request.
Be proactive: If your provider hasn’t heard back, follow up yourself with the insurance company.
Check your benefits summary: It often includes a list of services that need prior authorization.
Ask questions: Don’t be afraid to ask your doctor’s office or insurer for updates and clarification.
Advocating for Yourself
Navigating prior authorization can feel overwhelming, but being informed helps. If you feel stuck:
Contact a patient advocate through your hospital or healthcare provider
Ask if your provider has a prior authorization specialist
Use assistance programs through pharmaceutical companies (for medication denials)
Final Thoughts
Prior authorization is meant to protect patients and control costs—but it often adds delays and confusion to getting care. By knowing what services require approval, how to start the process, and what to do if you face a denial, you can take charge of your healthcare journey. Stay informed, stay organized, and don’t be afraid to speak up for your needs. With the right approach, you can get the coverage and care you deserve—without the unnecessary roadblocks.
