Prior Authorization
Advance approval required from a health insurer before certain medical services or prescription drugs will be covered.
What is Prior Auth (PA)?
Prior authorization (PA), also called pre-authorization or pre-certification, is a requirement by health insurance plans that certain medical services, procedures, medications, or devices receive insurer approval before they are provided, in order to confirm the treatment is medically necessary and covered under the plan. Common services requiring PA include specialist referrals (in some plans), elective surgeries, certain imaging studies (MRI, CT), brand-name or specialty drugs, and inpatient hospital admissions. The provider typically initiates the PA request, submitting clinical documentation to the insurer. Insurers may approve, deny, or request additional information. Denials can be appealed. If a patient receives a service requiring PA without obtaining it, the insurer may deny the claim or require the patient to pay a higher share. PA requirements have been criticized for delaying care and adding administrative burden on providers.
Example
A physician orders an MRI for a patient with persistent back pain. The health plan requires prior authorization for non-emergency MRIs. The physician submits clinical notes documenting failed conservative treatments. The insurer reviews the request and approves it within 3 days. Without this approval, the MRI would not be covered and the patient would face the full cost.