What Is Prior Authorization?
When a plan may require approval before certain services or medications.
Some health plans require approval before certain services or medications are covered. This process is called prior authorization. This module explains what it is and what questions to ask.
What is prior authorization?
Prior authorization is a process in which a health plan may require approval before certain services, procedures, or medications are covered. It is sometimes called preauthorization or precertification.
Your provider usually submits the request to the plan. The plan reviews it and makes a decision.
When it may apply
Depending on the plan, prior authorization may apply to things like:
- Certain imaging, such as MRI or CT scans.
- Certain procedures or hospital stays.
- Certain prescription medications.
- Certain medical equipment or therapies.
Each plan has its own list. Check your plan documents or ask your plan.
Authorization does not necessarily guarantee payment
Prior authorization vs. referral
| Prior authorization | Referral | |
|---|---|---|
| What it is | Approval from the health plan before certain services or medications | Direction from your primary care provider to see a specialist, often required by HMOs |
| Who gives it | The health plan | Usually your primary care provider |
| Common with | Many plan types | Often HMOs |
Real-life example: An MRI (fictional example)
Anna’s doctor orders an MRI. Before scheduling, Anna asks the doctor’s office whether her plan requires prior authorization for this service. The office submits the request, and Anna waits for the plan’s decision before the appointment. She also checks that the imaging center is in-network with her specific plan.
Key takeaways
- Prior authorization is a plan’s approval process for certain services or medications.
- Authorization does not necessarily guarantee payment.
- Prior authorization and a referral are different things.
- Ask your provider and plan whether authorization is needed before non-emergency care.
Educational information only. Examples are fictional and do not describe any real insurer or plan. Health-plan terms and requirements vary — always verify information using your official plan documents. Read the disclaimer.