Permission your doctor has to get before your insurance will cover certain care.
Prior authorization (PA) — sometimes called pre-authorization or pre-approval — is a requirement that your doctor get approval from your insurance company before you receive certain medical services, medications, or procedures.
Insurance companies use prior authorization to review whether a treatment is medically necessary and appropriate before they agree to pay for it. In theory, it prevents unnecessary care. In practice, it often delays necessary care.
If your doctor performs a service that required prior authorization and didn't get it, your insurance can deny the claim entirely — leaving you with the full bill.
Your doctor's office is typically responsible for submitting the prior authorization request. But that doesn't mean you're off the hook — it's worth confirming they submitted it and that it was approved before you schedule the procedure.
Ask your doctor to submit an appeal with detailed clinical documentation. You can also appeal directly as a patient. The same appeals process that applies to claim denials applies to prior authorization denials.
Prior authorization is one of the most criticized aspects of the U.S. health insurance system. A 2023 AMA survey found that 94% of physicians said PA causes delays in necessary care. New federal rules are pushing for faster PA timelines — but the system still puts significant burden on both patients and physicians.