What does Prior authorization mean?

Prior authorization is a health plan's advance review process for certain services, treatments, prescriptions, equipment, or supplies. The plan may require a clinician or facility to submit clinical and administrative information before the item or service is provided. The plan then decides whether its stated coverage criteria are met. Other names include preauthorization, prior approval, and precertification.

An authorization is not a guarantee that the plan will pay the claim. Eligibility, network status, coding, benefit limits, changes in the service, and other claim rules can still affect coverage and patient responsibility. Before scheduled care, ask both the provider and plan whether authorization is required, who is submitting it, what exact service and dates it covers, and whether written confirmation is available. Keep the reference number and decision notice. If a claim is denied for missing or mismatched authorization, read the denial reason and appeal instructions promptly; emergency-care rules and appeal rights can differ, so rely on the plan's current notice and applicable law.