Prior Authorization
Approval from your insurer before receiving a service — required for many procedures, medications, and referrals. Skipping it is the most common reason for a preventable denial.
Prior authorization (also called pre-authorization or pre-cert) is a requirement that your insurer approve a service before it’s provided. Without it, the insurer may deny the claim even if the service would otherwise be covered.
When it’s required
Insurers typically require prior authorization for:
- Non-emergency surgeries and procedures
- Specialty medications (especially biologics)
- Certain imaging studies (MRI, CT, PET)
- Out-of-network specialist visits
- Fertility treatments and durable medical equipment
What to do if authorization wasn’t obtained
If a service was denied because prior authorization wasn’t obtained, you can appeal. The strongest appeals show that: (1) the service was medically necessary, and (2) you or your provider attempted to get authorization but received incorrect guidance from the insurer’s staff.
Always get authorization confirmation numbers in writing — a verbal approval that can’t be verified is not useful in an appeal.
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