Prior Authorization Explained

What Is Prior Authorization?

Prior authorization (also called prior auth, pre-authorization, or pre-certification) is a requirement by your health insurer that you receive approval before getting certain medical services, procedures, medications, or tests. Without prior authorization when it is required, your claim may be denied — meaning you pay the full cost out of pocket even if the service is otherwise covered by your plan.

What Commonly Requires Prior Authorization

• Elective surgeries (joint replacements, bariatric surgery, many spine procedures)
• High-cost specialty medications (biologics, cancer drugs, GLP-1 medications like Ozempic/Wegovy)
• Advanced imaging: MRI, CT scans, PET scans for non-emergency conditions
• Mental health and substance use disorder inpatient admissions
• Durable medical equipment (wheelchairs, CPAP machines)
• Extended physical, occupational, or speech therapy
• Specialty care referrals on some HMO plans
• Home health care and infusion therapy

How to Get Prior Authorization

Prior authorization is usually initiated by your physician’s office, not by you directly. When your doctor recommends a test, procedure, or medication that requires prior auth, their billing staff submits a request to your insurer with clinical documentation supporting medical necessity. The insurer reviews the request and approves or denies it.

Timelines vary: urgent prior auth requests must be processed within 72 hours under federal rules; non-urgent requests within 15 calendar days. If you need to schedule something, make sure the prior auth request is submitted well before your intended appointment date.

If Prior Authorization Is Denied

A prior authorization denial is not the end. You (or your doctor) can appeal. Key steps:

1. Request the reason for denial in writing
2. Have your doctor submit additional clinical documentation if the denial was for “lack of medical necessity”
3. Request a peer-to-peer review: your doctor speaks directly with the insurer’s medical reviewer — this reverses denials more often than a written appeal alone
4. File a formal appeal within your plan’s appeal deadline (typically 60–180 days)
5. Request an external review if internal appeals fail — an independent physician reviews the case under federal and state rules