Prior Authorization

Approval before the care

Prior authorization, sometimes called preauthorization or precertification, is a step where your health plan reviews a treatment before you get it. The plan checks whether the service is medically necessary and whether a lower-cost option might work. If you skip it when it is required, the plan can refuse to pay.

Your doctor's office usually submits the request, but it is your coverage on the line, so it pays to know the rules.

Services that commonly need approval

• Advanced imaging like MRIs, CT and PET scans.
• Planned hospital admissions and many surgeries.
• Specialty and some brand-name medications.
• Durable medical equipment such as CPAP machines.
• Physical therapy beyond a set number of visits.
• Some mental health and substance use treatment programs.

Emergency care does not require prior authorization.

Example

Sofia, a self-employed bookkeeper, injures her back. Her doctor recommends an MRI.

1. The doctor's office sends a prior authorization request to her plan with her symptoms and notes from her visit.
2. The plan asks for documentation that she tried physical therapy first. Her doctor provides it.
3. The plan approves the MRI at an in-network imaging center, and she pays her normal cost sharing.

If she had gone straight to an imaging center without approval, the plan could have denied the claim and left her with the full bill.

If your request is denied

A denial is not the final word:

• Ask your doctor to request a peer-to-peer review, where they speak directly with the plan's medical reviewer.
• File an internal appeal with the insurer. ACA-compliant plans must provide one.
• If the appeal fails, request an external review by an independent reviewer.
• For urgent situations, ask for an expedited review.

Keep copies of everything, and note dates and names when you call.

Marketplace vs private plans

Both Marketplace and private plans use prior authorization, and the list of services that need it varies by plan, not by whether it is on or off the exchange. ACA-compliant plans must offer internal and external appeals. Plans that are not ACA-compliant may have different appeal processes, so read the policy terms before you buy. Some private plans also require precertification for hospital stays and reduce benefits if you skip it.

Tips to avoid problems

• Ask your doctor whether a service needs approval before it is scheduled.
• Call the insurer to confirm approval was granted and for which provider and date.
• Check whether approval is tied to a specific facility, since changing locations may require a new request.

An annual health insurance plan review is a good time to check how a plan handles approvals for the care you use. To compare plans with your medications and procedures in mind, request a quote.