Quick answer: prior authorization (also called preauthorization or precertification) is approval from your health plan before you get certain care, such as some surgeries, imaging, specialty drugs or durable medical equipment. Your doctor’s office usually submits the request. Under a federal rule from CMS, Medicare Advantage, Medicaid, CHIP and federally facilitated Marketplace plans must generally decide standard requests within 7 calendar days and urgent requests within 72 hours starting in 2026. If a request is denied, you can ask for the reason and appeal.
Few things in health insurance cause as much frustration as prior authorization. A doctor recommends a test or medication, and then everyone waits for the insurance company to approve it. Sometimes approval comes quickly; sometimes it takes days, requires extra paperwork or ends in a denial.
Understanding how prior authorization works helps you avoid surprise bills, keep care on track and push back when a request is denied. This article explains the process step by step and what you can do at each stage. For a broader overview of plan types, costs and coverage, see our complete health insurance guide.
This is general information, not medical, legal or insurance advice. Sources: HealthCare.gov glossary (preauthorization); Centers for Medicare and Medicaid Services, Interoperability and Prior Authorization Final Rule (CMS-0057-F, January 2024); Medicare.gov; U.S. Department of Labor and HealthCare.gov on internal and external appeals; Affordable Care Act protections for emergency services. Rules vary by plan and state. Checked October 2026. Questions about this article: hello@proinsuranceinfo.com.
What Is Prior Authorization?
HealthCare.gov defines preauthorization as a decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. It is sometimes called prior authorization, prior approval or precertification.
Why insurers use it
Health plans say prior authorization helps confirm that care is medically necessary, follows clinical guidelines and is delivered in a cost-effective setting. Critics, including many physician groups, say it delays care and creates administrative burden.
Approval is not a payment guarantee
HealthCare.gov notes that preauthorization is not a promise that the plan will cover the cost. Coverage still depends on your plan terms, eligibility and whether the claim matches what was approved.
Services That Commonly Require Prior Authorization
Every plan has its own list, but services that often need approval include:
| Category | Common examples |
|---|---|
| Imaging | MRI, CT and PET scans |
| Surgery and procedures | Many planned inpatient and outpatient surgeries |
| Specialty drugs | Biologics, injectable medications, some brand-name drugs |
| Durable medical equipment | CPAP machines, wheelchairs, home oxygen |
| Therapy | Physical, occupational and speech therapy beyond a set number of visits |
| Behavioral health | Some inpatient and intensive outpatient programs |
| Home health and skilled nursing | Home health visits, skilled nursing facility stays |
| Genetic testing | Many genetic and specialized lab tests |
Where to find your plan’s list
Check your plan’s member website, Summary of Benefits and Coverage, drug formulary or member handbook. Formularies often mark drugs that require prior authorization with “PA.”
Emergencies are different
Under the Affordable Care Act, most health plans cannot require prior authorization for emergency services, whether the emergency room is in or out of network. If you have an emergency, get care first.
Medicare Advantage and Medicaid managed care plans
Prior authorization is especially common in Medicare Advantage plans and in Medicaid managed care organizations (MCOs), the private plans many states use to deliver Medicaid benefits. Under a CMS rule that took effect in 2024, Medicare Advantage plans must generally follow Traditional Medicare coverage criteria, may use prior authorization only to confirm a diagnosis or other medical criteria and that care is medically necessary, must treat an approval as valid for as long as medically necessary for a course of treatment, and must give new enrollees a transition period of at least 90 days for ongoing treatment.
How the Prior Authorization Process Works
- Your provider recommends care that your plan requires approval for.
- The provider’s office submits a request to the plan, usually with medical records, test results and notes explaining why the care is needed.
- The plan reviews the request. Reviewers compare it with the plan’s medical policies and clinical criteria.
- The plan may ask for more information, which can pause the clock.
- The plan makes a decision: approved, partially approved or denied.
- You and your provider are notified. If approved, the authorization usually covers a set service, time period or number of visits.
Who is responsible for getting it?
In-network providers usually handle prior authorization for you. If you see an out-of-network provider, you may be responsible for getting approval yourself. Check your plan documents to be sure.
Medical necessity and documentation requirements
Most prior authorization decisions turn on medical necessity: whether the requested care is appropriate and needed for your condition under the plan’s clinical criteria. To show this, the authorization process usually requires documentation such as your diagnosis, relevant test results, treatments you have already tried and the provider’s notes explaining why this service is needed now. Missing or incomplete documentation is a common reason for delays and denials, so ask your provider’s office whether everything was sent.
How Long Prior Authorization Takes
Timelines depend on your plan type and whether the request is urgent.
The CMS Interoperability and Prior Authorization Final Rule
In January 2024, the Centers for Medicare and Medicaid Services finalized a rule (CMS-0057-F) that applies to Medicare Advantage plans, state Medicaid and CHIP programs, Medicaid managed care plans, CHIP managed care entities and qualified health plan issuers on the federally facilitated Exchanges. Beginning in 2026, these plans must generally:
- Decide expedited (urgent) requests within 72 hours
- Decide standard requests within 7 calendar days
- Give a specific reason when they deny a request
- Publicly report certain prior authorization metrics
The rule also requires these plans to build electronic prior authorization systems, with key technical requirements starting in 2027.
Employer plans
Many employer plans follow timelines set by federal claims rules and state law. Urgent requests generally must be decided faster than routine ones. Check your plan’s Summary Plan Description for exact timelines.
Speeding things up
- Ask your provider’s office when the request was sent.
- Call the plan to confirm it was received and whether anything is missing.
- If your situation is urgent, ask your doctor to request an expedited review.
What Happens If You Skip Prior Authorization?
If your plan requires approval and none was obtained, the plan may reduce payment or deny the claim. Depending on your plan and whether the provider was in network, you may be responsible for some or all of the bill. In-network providers often cannot bill you for services denied because they failed to get required approval, but rules vary, so ask before agreeing to pay.
Understanding your plan’s cost-sharing also matters. Our guide to the deductible, copay, coinsurance and out-of-pocket maximum explains what you will owe even when care is approved.
Step Therapy and Prior Authorization for Drugs
What is step therapy?
Step therapy requires you to try a lower-cost or preferred drug first, and only move to the prescribed drug if the first one does not work. It often goes hand in hand with prior authorization.
Exceptions
Most plans allow your prescriber to request an exception, for example if you already tried the preferred drug, it caused side effects or it is not appropriate for your condition. Many states have laws that set rules for step therapy exceptions in state-regulated plans.
Medicare Part D
Medicare drug plans may use prior authorization and step therapy. Medicare.gov explains that you or your prescriber can request a coverage determination or exception.
What to Do If Prior Authorization Is Denied
1. Read the denial notice
The notice should explain why the request was denied and how to appeal. Under the CMS rule, impacted plans must give a specific reason.
2. Talk with your provider
Many denials result from missing information. Your doctor may be able to resubmit with more documentation or request a peer-to-peer review, a conversation between your doctor and the plan’s medical reviewer.
3. File an internal appeal
You have the right to ask your plan to reconsider. Under the Affordable Care Act, most plans must allow an internal appeal, and HealthCare.gov notes you generally have 180 days from the denial notice to file.
4. Request an external review
If the internal appeal is denied, you can usually request an independent external review. When the external reviewer decides in your favor, the plan must accept that decision.
5. Ask for an expedited appeal if urgent
When waiting could seriously harm your health, ask for an expedited appeal.
Our step-by-step guide on how to appeal a denied health insurance claim walks through letters, documents and deadlines.
Prior Authorization Versus Referrals
People often confuse prior authorization with referrals, but they are different requirements.
| Referral | Prior authorization | |
|---|---|---|
| Who gives it | Your primary care provider | Your health plan |
| What it allows | Seeing a specialist or getting certain services | Coverage of a specific service, drug or device |
| Common in | HMO and some POS plans | Most plan types |
| Typical paperwork | A note or order from your doctor | A formal request with medical records |
Some care requires both. For example, an HMO member might need a referral to see an orthopedic specialist and then prior authorization before an MRI the specialist orders. Our explanation of Marketplace metal levels covers how plan designs differ.
Questions to Ask Your Provider's Office
- Does this service, test or drug require prior authorization under my plan?
- Has the request been submitted, and on what date?
- What documentation was included?
- Is this request standard or expedited?
- Who should I contact if I have not heard back?
- If it is denied, will you request a peer-to-peer review or resubmit?
What to Say When You Call Your Health Plan
A short, organized call gets better results. Have your member ID card, the provider’s name, the service or drug and the date of the request ready.
A simple script: “I’m calling to check the status of a prior authorization request submitted by Dr. [name] on [date] for [service]. Can you confirm it was received, whether any information is missing and when a decision is expected?”
Write down the representative’s name, the date and the call reference number. If a decision is overdue under your plan’s timelines, ask how to file a complaint or grievance.
Getting Help With Prior Authorization
Free help is available if you get stuck. Many states have consumer assistance programs that help people with health insurance appeals; HealthCare.gov lists contacts by state. For employer plans, the U.S. Department of Labor’s Employee Benefits Security Administration offers assistance by phone and online. Medicare beneficiaries can contact their State Health Insurance Assistance Program (SHIP) for free counseling.
Tips to Avoid Prior Authorization Delays and Denials
- Ask early: when your doctor recommends a test, procedure or new drug, ask whether prior authorization is needed.
- Keep records: write down call dates, names and reference numbers.
- Check approval details: confirm the approved dates, number of visits, facility and provider.
- Watch expiration dates: approvals often expire after a set time.
- Reconfirm after plan changes: a new plan year or new insurance may require a fresh authorization. Our guide to open enrollment and special enrollment periods explains when plan changes happen.
- Ask about continuity of care: if you switch plans mid-treatment, ask the new plan about transition coverage.
- Get approvals in writing: request a copy of the approval letter or a screenshot from the member portal, and bring it to your appointment.
- Double-check the location: an approval for one facility or provider may not apply if your care moves to another hospital, imaging center or pharmacy.
Prior Authorization in Traditional Medicare
Original Medicare has historically used prior authorization for relatively few services, such as certain durable medical equipment and some hospital outpatient procedures. Medicare Advantage plans use it much more often. If you are comparing Medicare options, ask how each plan handles prior authorization for services you expect to need.
Prior authorization versus pre-claim review
Traditional Medicare also uses a related process called pre-claim review. According to CMS, the two differ mainly in timing. With prior authorization, the provider submits the request and gets a decision before the service is provided. With pre-claim review, the provider can begin or even complete the service first, but must get a decision before submitting the final claim. Pre-claim review is used, for example, in the Review Choice Demonstration for home health services in certain states.
In both programs, the provider sends the request with supporting medical records to a Medicare Administrative Contractor (MAC), which issues an affirmed or non-affirmed decision. An affirmed decision means the claim likely meets Medicare coverage, coding and payment rules. A non-affirmed decision means it likely does not, and the MAC explains what was missing; the provider can correct and resubmit. CMS says these programs do not change medical necessity or documentation requirements; they move the review earlier.
Prior Authorization Regulatory Requirements and Industry Changes
Prior authorization has received attention from regulators and insurers. In addition to the CMS rule, a group of health insurers announced commitments in 2025 to streamline prior authorization, including reducing the number of services that need it and expanding electronic processing. How these commitments affect individual plans will vary, so always check your own plan’s current rules.
Frequently Asked Questions
What is prior authorization in health insurance?
It is approval from your health plan before you receive certain services, drugs or equipment, confirming the plan considers the care medically necessary.
Who submits a prior authorization request?
Usually your doctor’s office. With out-of-network care, you may be responsible.
How long does prior authorization take?
It varies. Under the CMS rule, many government-related plans must decide urgent requests within 72 hours and standard requests within 7 calendar days starting in 2026.
Is emergency care subject to prior authorization?
Under the Affordable Care Act, most plans cannot require prior authorization for emergency services.
Can I appeal a prior authorization denial?
Yes. You can file an internal appeal with the plan and, if needed, request an external review.
What is medical necessity in prior authorization?
Medical necessity means the requested care is reasonable and needed to diagnose or treat your condition according to the plan’s clinical criteria. The prior authorization request should include documentation showing why the service is needed.
What is the difference between prior authorization and pre-claim review?
In Traditional Medicare, prior authorization happens before a service is provided, while pre-claim review lets the provider begin the service but requires a decision before the final claim is submitted. Both result in an affirmed or non-affirmed decision from a Medicare contractor.
Sources
- HealthCare.gov. Glossary: Preauthorization; Appealing a health plan decision.
- Centers for Medicare and Medicaid Services. CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), January 2024.
- Medicare.gov. Drug plan coverage rules: prior authorization and step therapy.
- U.S. Department of Labor. Claims and appeals guidance for employer plans.
- Centers for Medicare & Medicaid Services. Prior Authorization and Pre-Claim Review Initiatives.
- Centers for Medicare & Medicaid Services. Review Choice Demonstration for Home Health Services, Operational Guide.
- Centers for Medicare & Medicaid Services. 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F).
