What is a pre-authorization requirement in health insurance?

2 min. readlast update: 10.17.2023

A pre-authorization requirement, also known as pre-authorization or prior authorization, is a process used by health insurance companies to determine if they will cover certain medical services or treatments before they are provided. It is a way for insurers to ensure that the proposed medical services are medically necessary and appropriate for the patient's condition.

Here's how the pre-authorization process generally works:

  1. Identification of Services: When a healthcare provider recommends a specific medical service or treatment, such as a surgery, diagnostic test, or certain medications, they or their staff identify if the service requires pre-authorization from the health insurance company.
  2. Pre-Authorization Request: The healthcare provider or their staff will submit a pre-authorization request to the health insurance company. This request includes relevant medical information, such as the diagnosis, the proposed treatment or service, and supporting documentation such as medical records, test results, and clinical justification.
  3. Review by the Insurance Company: The health insurance company reviews the pre-authorization request to assess the medical necessity and appropriateness of the recommended service. They evaluate the information provided and compare it to their coverage policies and guidelines.
  4. Decision and Notification: Based on their review, the insurance company will make a decision to approve or deny the pre-authorization request. They communicate their decision to both the healthcare provider and the insured individual. The decision may be made relatively quickly for urgent or emergency situations, while non-urgent requests may take several days or weeks.
  5. Coverage Determination: If the pre-authorization request is approved, the health insurance company confirms coverage for the specific service or treatment. The insured individual and healthcare provider can proceed with the planned medical care, knowing that it will be covered by the insurance plan. If the request is denied, the insurer will provide a reason for the denial, and the insured individual and healthcare provider may explore alternative options or submit an appeal, if appropriate.

It's important to note that not all medical services require pre-authorization. The specific procedures, treatments, medications, and thresholds for pre-authorization can vary among insurance plans and may depend on factors such as the insurance policy, medical necessity, cost, and the specific guidelines set by the insurance company.

To avoid unexpected costs or coverage issues, it's advisable to review your health insurance policy, understand the pre-authorization requirements, and consult with your healthcare provider to determine if pre-authorization is necessary for any planned medical services.

Was this article helpful?