Prior authorization is your insurance company's requirement that your doctor get approval before you receive certain medical services, medications, or procedures.
When your doctor prescribes a treatment, orders imaging, or recommends surgery, your insurance plan may require them to submit a request to the insurer first. The insurer reviews whether the treatment meets their coverage rules for your condition. If approved, you can move forward. If denied, you either pay out of pocket, try a different treatment the plan does cover, or appeal the decision.
Prior authorization exists because insurers use it to manage costs and prevent unnecessary procedures. It also protects you from paying for treatments your plan won't cover — you find out before the bill arrives. But the process adds time between your doctor's recommendation and your actual care, which is why understanding how it works matters.
Key Takeaways
- Prior authorization means your doctor must request approval from your insurance company before you receive certain treatments, medications, or procedures.
- Your doctor's office typically submits the authorization request, not you, and they usually handle the back-and-forth with the insurance company.
- The insurer usually responds within 24 to 72 hours for routine requests, though urgent or emergency care may be approved differently.
- If your request is denied, you can ask your doctor to appeal or request a peer-to-peer review where your doctor speaks directly with the insurer's medical reviewer.
- Emergency or urgent care often bypasses prior authorization, but you should notify your insurer as soon as possible afterward.
Why Insurance Companies Require Prior Authorization
Insurance plans use prior authorization to verify that a treatment is medically necessary for your specific condition and that it follows the plan's clinical guidelines. Without this step, insurers would pay for treatments that might not be the most effective option or that duplicate other care you're already receiving.
From your perspective, prior authorization also prevents surprise bills. If your doctor orders an MRI that your plan doesn't cover for your symptoms, you learn that before the scan happens — not after you receive a bill for thousands of dollars. The insurer's approval means the treatment is covered under your plan, assuming you've met any deductible or cost-sharing requirements.
The downside is delay. Your doctor may need to wait days for approval, which can postpone your care. For non-urgent situations, this is usually manageable. For time-sensitive conditions, it can be frustrating.
Which Services Typically Require Prior Authorization
Prior authorization requirements vary by insurance plan, but common services include specialty referrals, imaging (MRI, CT scans, PET scans), certain medications (especially newer or expensive drugs), mental health treatment beyond a set number of visits, physical therapy, surgery, and hospital admissions.
Your insurance plan's website or member handbook lists which services need prior authorization. You can also call the number on your insurance card and ask whether a specific treatment requires it. Your doctor's office usually knows too — they submit authorization requests regularly and can tell you whether one is needed before they schedule your appointment.
Routine office visits, preventive care, and emergency room visits typically do not require prior authorization, though this varies by plan. Some plans require authorization for specialist visits; others do not.
How to Request Prior Authorization
Your doctor's office handles the prior authorization request in most cases. When your doctor recommends a treatment that requires authorization, their staff contacts your insurance company with your medical information, the reason for the treatment, and supporting documentation. You do not need to submit the request yourself.
The insurer's medical team reviews the request against their clinical guidelines. They may approve it when ready, request more information from your doctor, or deny it. Your doctor's office receives the decision and notifies you. If approved, you can schedule your appointment or fill your prescription. If denied, your doctor can explain why and discuss alternatives.
In some cases, you may need to provide information — for example, proof that you tried a less expensive medication first, or documentation of your symptoms. Your doctor's office will tell you what they need and help you gather it.
What Happens If Prior Authorization Is Denied
A denial does not mean you cannot have the treatment. It means your insurance plan will not cover it under their current rules. You have several options: pay for it yourself, try a different treatment your plan does cover, or challenge the decision.
The most common next step is an appeal or peer-to-peer review. Your doctor can request that a physician at the insurance company review the decision. This is different from the initial review — a doctor speaks directly with another doctor about your case, which sometimes results in approval. Your doctor's office handles this request; you do not need to contact the insurer yourself.
If the appeal is also denied, you may have a formal grievance process through your insurance plan. Your plan's member handbook explains how to file a grievance and what timeline the insurer must follow to respond.
How Long Prior Authorization Takes
Most insurance companies respond to prior authorization requests within 24 to 72 hours. Some plans promise faster turnaround for urgent requests. Your doctor's office can mark a request as urgent if your condition requires faster care, and the insurer typically prioritizes these.
In practice, the timeline depends on how complete your doctor's request is. If the insurer needs more information, the clock resets when your doctor provides it. This is why it helps to ask your doctor's office how long they expect the process to take and whether there are any documents you should gather in advance.
Emergency care does not wait for prior authorization. If you go to the emergency room or need when ready treatment, you receive care first. You or your doctor should notify your insurer within 24 to 48 hours afterward, and the insurer will determine whether the emergency care is covered.
Prior Authorization for Medications
Prescription medications often require prior authorization, especially newer drugs, expensive treatments, or medications for specific conditions. Your doctor submits the authorization request to your insurance company, and the pharmacy waits for approval before filling your prescription.
If your medication is denied, your doctor can request an exception or appeal. Sometimes the insurer will approve the medication if your doctor documents that you tried a cheaper alternative first and it did not work, or if there is a medical reason you cannot take the preferred medication.
In urgent situations, your pharmacy may fill a small supply of your medication while authorization is pending, so you do not run out. Ask your pharmacist whether this is possible if your authorization is delayed.
Frequently Asked Questions
Do I have to pay for a service while prior authorization is pending?
No. If your doctor schedules a procedure or your pharmacy fills a prescription before authorization is approved, you should not be charged if the authorization is later denied — that is the insurer's responsibility. However, if you choose to proceed without authorization, you may be responsible for the full cost. Always confirm with your doctor or pharmacy before moving forward.
What if my doctor says the treatment is urgent?
Tell your doctor's office to mark the authorization request as urgent. Most insurers prioritize these and respond within 24 hours. If your condition is truly emergent, you can receive care in the emergency room without waiting for authorization. Notify your insurer within 24 to 48 hours, and they will determine coverage.
Can I appeal a prior authorization denial?
Yes. Your doctor can request a peer-to-peer review, where a physician at the insurance company speaks directly with your doctor about the decision. If that is also denied, you can file a formal grievance through your insurance plan. Your member handbook explains the grievance process and timeline.
Who pays for prior authorization?
Your doctor's office submits the request at no charge to you. Prior authorization is part of how insurance plans operate, and the cost is built into your premiums and plan structure. You do not pay a separate fee for the authorization process itself.
Can I get prior authorization for something my plan does not usually cover?
You can request an exception, and your doctor can appeal on your behalf. Whether the insurer grants an exception depends on your specific situation and the plan's rules. A peer-to-peer review with your doctor sometimes results in approval when the initial request was denied.