Bills and insurance
What Is Prior Authorization in Health Insurance?
Prior Authorization · say it: PRY-er aw-thor-ih-ZAY-shunAlso written: prior auth, PA, preauthorization, pre-approval, precertification
Short answer
Prior authorization is approval your insurer must give before it will cover certain treatments, tests or medicines.
What it means
Some insurance plans require your doctor to get permission before they will pay for specific services, such as some scans, procedures, hospital stays or expensive medicines. That permission is prior authorization.
When it appears on a letter, pharmacy notice or bill, the insurer is telling you where the approval stands. Your doctor's office usually sends the request with medical information explaining why the service is needed. The insurer may approve it, ask for more information, suggest an alternative, or deny it. If a required approval was never obtained, the insurer may refuse to pay the claim.
Prior authorization is different from a referral. A referral is your main doctor sending you to a specialist, while prior authorization is the insurer agreeing in advance to cover a particular service. Some plans need both.
Where you may see it
- Insurance letters and online portal messages about a pending or decided request
- Pharmacy notices saying a prescription cannot be filled until the insurer approves it
- Explanation of benefits (EOB) statements and claim denials
- Scheduling calls for MRI or CT scans and planned surgery
📄 How it looks on a report
Claim denied: prior authorization required and not obtained.
🙅 What it does not mean
- Needing prior authorization does not mean your doctor thinks the treatment is unusual or risky. It is a rule set by your insurance plan.
- A denial is not always the end. There is usually an appeal process, and your doctor's office can often send more information.
- Approval is not a promise of full payment. Your deductible, copay and coinsurance can still apply, and approvals often expire after a set time.
🗒️ Questions to ask your doctor
🧾 Reports where you will see “Prior Authorization”
Paste or upload the report and every line of it is explained, with personal details removed first.
🔗 Read more from trusted sources
- “Prior Authorization” on MedlinePlus ↗
US National Library of Medicine
- HealthCare.gov glossary ↗
US government health insurance glossary
Seeing this word on your own report? Get every line of it explained, free.
Explain my report🧩 Related words
🔎 Look up another word
More words: bills and insurance
General information about a medical word, not advice about your own results. Ask the clinician who ordered the test what it means for you.