Prior authorization is your insurance company's approval before you receive certain medical services, medications, or procedures

When your doctor prescribes a treatment, orders a scan, or recommends surgery, your insurance company may require prior authorization — a formal sign-off before the service happens. Without it, you may face a denied claim, a surprise bill, or a delay in care. Prior authorization exists because insurers want to confirm that a treatment is medically necessary and covered under your plan before paying for it.

The process typically involves your doctor's office submitting clinical information to your insurance company, which then reviews it against your plan's coverage rules. This can take anywhere from a few hours to several business days, depending on the complexity of the request and how quickly your doctor responds to any follow-up questions from the insurer.

Prior authorization is different from a referral. A referral is permission to see a specialist; prior authorization is permission for a specific service or drug. You may need both, or just one, depending on your plan and the type of care you need.

Key Takeaways

  • Prior authorization is your insurance company's approval for a specific treatment, medication, or procedure before you receive it.
  • Your doctor's office usually handles the request, but you should confirm they have submitted it and know the expected timeline.
  • If your claim is denied at the authorization stage, you have the right to appeal the decision and provide additional medical information.
  • Some urgent or emergency services bypass prior authorization, but you should verify this with your insurer before assuming coverage.
  • Delays in prior authorization can postpone your care, so asking your doctor to submit the request as soon as possible reduces wait time.

Which services and medications typically require prior authorization

Not every service needs prior authorization. Routine office visits, preventive care, and emergency services usually do not. However, certain categories almost always do: specialty medications, imaging scans (MRI, CT, PET), mental health treatment beyond a set number of sessions, physical therapy, durable medical equipment, and many surgical procedures.

Prescription drugs are a common trigger. Your insurer may require prior authorization for brand-name medications when a generic alternative exists, for medications that treat certain conditions, or for drugs that are expensive or have a high risk of misuse. Some insurers also require it for biologics, injectables, and specialty pharmaceuticals.

Imaging and diagnostic tests often need authorization because they are costly and insurers want to confirm they are medically necessary. Mental health and substance use treatment may require authorization for sessions beyond a certain threshold, or for inpatient care. Durable medical equipment — wheelchairs, oxygen, CPAP machines — frequently requires it as well.

Your insurance plan documents or your insurer's website will list which services require prior authorization. If you are unsure, call your insurance company or ask your doctor's office before scheduling.

How the prior authorization process works

The process begins when your doctor decides you need a service or medication. Your doctor's office contacts your insurance company — usually by phone, fax, or an online portal — and submits your clinical information: your diagnosis, medical history, why this specific treatment is necessary, and what alternatives have been tried.

Your insurance company reviews the request against your plan's coverage rules and medical policy. This review is typically done by a nurse or medical reviewer, sometimes with input from a physician. They determine whether the treatment meets the criteria for coverage under your plan.

You will receive a decision in one of three forms: approval (the service is covered), denial (the service is not covered under your plan), or conditional approval (the service is covered only if certain conditions are met — for example, only after you have tried a cheaper medication first).

The timeline varies. Routine requests may be approved within 24 hours. Complex cases, especially those involving surgery or specialty drugs, can take 3 to 5 business days. Your doctor's office should tell you how long to expect and follow up if you do not hear back within that window.

What to do if your prior authorization is denied

A denial does not mean you cannot receive the service — it means your insurance company has determined it does not meet their coverage criteria. You have the right to appeal.

Start by asking your doctor's office for the denial letter and the reason for the denial. Common reasons include: the treatment is not medically necessary according to the insurer's guidelines, you have not tried a required alternative first, or the service is not covered under your specific plan.

Work with your doctor to gather additional clinical evidence. This might include test results, specialist notes, or documentation that you have already tried other treatments without success. Your doctor can then submit an appeal with this new information, arguing why the treatment should be covered in your specific case.

If the appeal is denied, you can request an external review — an independent medical professional outside your insurance company will evaluate the decision. This process is required by law and is free to you. Your state's insurance commissioner's office can tell you how to request one.

How to speed up the prior authorization process

Ask your doctor to submit the prior authorization request as soon as the decision to treat is made, not the day before your appointment. The earlier the request goes in, the more time the insurer has to review it.

Confirm that your doctor's office has your correct insurance information and that they are submitting to the right insurance company. A wrong insurance ID or company name can cause delays or rejections.

Ask your doctor's office for a timeline and a contact person. Find out who at the insurance company is handling your request and how to check on its status. Many insurers have online portals where you can track the request yourself.

If you are told the request is pending after the expected timeframe, call your doctor's office and ask them to follow up with the insurer. Sometimes requests get lost or stuck in a queue, and a phone call can move things along.

For urgent or time-sensitive care, tell your doctor's office when ready. Some insurers have expedited review processes for urgent requests, which can reduce the timeline from days to hours.

Prior authorization for emergency and urgent care

Emergency services — care you receive in an emergency room for a life-threatening condition — typically do not require prior authorization. You should receive care first and deal with authorization afterward.

Urgent care is less clear. If you need care within 24 to 72 hours but it is not life-threatening, your insurer may still require prior authorization, but they should have a faster review process. Ask your doctor or the urgent care center to request expedited review and explain the timeline.

After emergency or urgent care, your doctor's office or the hospital will submit the claim to your insurer. The insurer will review it to confirm it was medically necessary. If they deny it, you can appeal using the same process as any other denial.

Frequently Asked Questions

What happens if I get a service without prior authorization?

Your claim may be denied, leaving you responsible for the full bill. Some insurers will still pay if your doctor can show the service was medically necessary, even without authorization. Call your insurer when ready if this happens and ask about the appeal process. Do not ignore a bill — respond to it and explain that authorization was not obtained.

Can I get prior authorization myself, or does my doctor have to do it?

Your doctor's office must submit the request because the insurer needs clinical information that only your medical records contain. You can call your insurer to ask about the status, but you cannot obtain authorization on your own. You can speed things up by reminding your doctor's office to submit it and following up if it is delayed.

How long does prior authorization usually take?

Routine requests are often approved within 24 hours. Complex cases involving surgery or specialty medications can take 3 to 5 business days. Urgent requests may be reviewed within a few hours. Ask your doctor's office for an expected timeline when the request is submitted.

Does prior authorization mean my insurance will definitely pay for the service?

Approval means your insurer has confirmed the service is covered under your plan and medically necessary. You are still responsible for your copay, coinsurance, or deductible. Approval does not may provide payment if you later miss a payment or if your coverage ends.

Can my doctor appeal if prior authorization is denied?

Yes. Your doctor can submit an appeal with additional clinical information explaining why the treatment is necessary in your case. If the appeal is denied, you can request an external review by an independent medical professional, which is free and required by law.