What prior authorization is and why insurers use it
Prior authorization is a requirement from your insurance company that your doctor must get approval before providing certain medical treatments, procedures, or medications. The insurer reviews the request to confirm the treatment is medically necessary and covered under your plan before your doctor performs it or writes the prescription.
Insurance companies use prior authorization to control costs and prevent unnecessary care. Without it, a doctor could order an expensive imaging scan or specialist visit, and the insurer would have to pay the bill after the fact. With prior authorization, the insurer can say no upfront — or ask the doctor to try a cheaper treatment first — before you receive the service.
The catch is that prior authorization takes time. Your doctor's office must submit paperwork to the insurer, wait for a decision, and sometimes go back and forth if the insurer denies the request. This delay can happen even when your doctor believes the treatment is necessary.
Key Takeaways
- Prior authorization is your insurer's approval process for certain treatments, medications, and procedures before your doctor provides them.
- Your doctor's office typically handles the request, but you should confirm they have submitted it and ask when you can expect a decision.
- If the insurer denies the request, your doctor can appeal or request a peer-to-peer review where another doctor discusses the case with your insurer.
- Some treatments require prior authorization; others do not — your insurance plan documents or customer service line will tell you which ones do.
- If you receive treatment without prior authorization and the insurer denies it later, you may be responsible for the full bill.
Which treatments and medications typically need prior authorization
Prior authorization requirements vary by insurance plan, but certain categories almost always need it. Specialty medications — particularly expensive drugs for cancer, rheumatoid arthritis, or hepatitis C — almost always require approval before your pharmacy fills the prescription. Imaging scans like MRI and CT scans often need it, especially if your doctor orders them for a condition that could be diagnosed with a cheaper X-ray first.
Mental health and substance abuse treatment frequently requires prior authorization, including inpatient rehabilitation stays and intensive outpatient programs. Certain surgeries and procedures — joint replacements, back surgery, cardiac catheterization — usually need it. Some plans also require prior authorization for specialist visits, though this is less common than it used to be.
Routine care like annual checkups, standard lab work, and preventive screenings almost never require prior authorization. The best way to know what your plan requires is to call your insurance company's customer service line or log into your online account and search for "prior authorization requirements" or "coverage policies."
How the prior authorization process actually works
Your doctor's office initiates the request. They contact your insurance company — by phone, fax, or online portal — and provide your medical information, the reason for the treatment, and why they believe it is necessary. The insurer reviews this information, usually within one to three business days, though some decisions take longer.
The insurer then sends a decision back to your doctor's office. If approved, you receive an authorization number, and your doctor can proceed. If denied, the office notifies you and your doctor. At this point, your doctor can appeal the decision, request a peer-to-peer review (where another physician discusses your case with the insurer's doctor), or suggest an alternative treatment that the insurer will cover.
You should not wait passively. Ask your doctor's office when they submitted the request and when they expect a response. If the decision is delayed and you need the treatment urgently, call your insurance company directly and ask for expedited review — many plans allow this for urgent or emergency situations. Get the authorization number in writing before you receive the treatment.
What happens if prior authorization is denied
A denial does not mean you cannot have the treatment — it means your insurer will not pay for it unless the decision is overturned. Your doctor can appeal by submitting additional medical information that supports the need for the treatment. This appeal process usually takes another five to ten business days.
If the appeal is also denied, your doctor can request a peer-to-peer review. This means a physician working for the insurer will speak directly with your doctor to discuss whether the treatment is medically necessary. These reviews sometimes overturn denials, especially if your doctor can explain why a cheaper alternative will not work for your specific situation.
If all appeals fail, you have a choice: pay for the treatment out of pocket, ask your doctor about covered alternatives, or decline the treatment. Some people choose to pay out of pocket for expensive medications or procedures if the insurer's approved alternatives have not worked in the past. Before you do, confirm with your doctor's office what the actual cost will be.
What you should do before receiving treatment that might need prior authorization
Ask your doctor at the appointment whether prior authorization is required for the treatment or medication they are recommending. If it is, ask them to submit the request that day if possible. Get the name of the person handling it and a phone number so you can follow up.
Call your insurance company yourself if you want to confirm the request was received. You do not need to wait for your doctor's office to do this — you can call and ask whether prior authorization is required, what information the insurer needs, and what the timeline is. Having this information yourself prevents delays caused by miscommunication between your doctor and the insurer.
If you are prescribed a medication, ask the pharmacy whether prior authorization is required before they fill it. Some pharmacies will not fill a prescription without it; others will fill it and bill your insurer, then ask you to pay if the insurer denies it later. Knowing this upfront prevents a surprise bill.
Prior authorization for urgent and emergency care
If you need urgent or emergency treatment, prior authorization should not delay care. Emergency rooms are not required to wait for authorization before treating you. However, after the emergency is over, your insurer may still review whether the treatment was necessary and covered under your plan.
For urgent care that is not life-threatening but cannot wait weeks for authorization, ask your doctor to request expedited review. Most insurers have a faster process for urgent cases — sometimes a decision within 24 hours instead of three to five days. Your doctor's office knows how to request this, but you can also call your insurer and ask for expedited review yourself.
How to appeal a prior authorization denial
Start by asking your doctor's office to file a formal appeal. They will submit additional medical records, test results, or a letter from your doctor explaining why the treatment is necessary. This is the first level of appeal and often succeeds if new information supports the need.
If the appeal is denied, request a peer-to-peer review in writing. Your doctor will speak with a physician at the insurance company. These reviews are more likely to overturn a denial because they involve a direct conversation between doctors rather than a paper review. Your doctor's office can request this, or you can call your insurer and ask for it yourself.
If you have exhausted the insurer's internal appeal process, you may have the right to an external review — an independent review by someone outside the insurance company. The rules for external review vary by state and by whether your plan is regulated by your state or by federal law. Your state's insurance commissioner's office can tell you whether you have this right and how to request it.
Frequently Asked Questions
Can I get treatment without prior authorization and pay for it myself?
Yes. If your insurer denies prior authorization and you want the treatment anyway, you can pay out of pocket. However, confirm the actual cost with your doctor's office first — some treatments are far more expensive than you might expect. You will not be able to use your insurance to cover any part of it.
What if my doctor's office forgets to get prior authorization?
If your doctor provides treatment without prior authorization and your insurer denies it afterward, you may be responsible for the bill. This is why you should confirm that authorization was obtained before you receive the treatment. If your doctor's office made the mistake, ask them to appeal on your behalf — many insurers will cover the bill if the doctor can show the treatment was medically necessary, even without prior authorization.
How long does prior authorization usually take?
Most decisions come back within one to three business days. Some take longer, especially if the insurer needs more medical information from your doctor. If you need the treatment urgently, ask your doctor to request expedited review, which can result in a decision within 24 hours.
Do I need prior authorization for specialist visits?
It depends on your plan. Some plans require it; many do not. Call your insurance company or check your plan documents to find out. If your plan does require it, your primary care doctor usually submits the request when they refer you to the specialist.
What is the difference between prior authorization and a referral?
A referral is permission from your primary care doctor to see a specialist, usually required by HMO plans. Prior authorization is permission from your insurer that they will cover a specific treatment or procedure. You may need both, or just one, depending on your plan type.