Bills and insurance
Prior authorization letter explainer
A prior authorization letter answers a request your doctor's office sent to your insurer, and the answer is spread across a status word, a reference number, a list of codes and a pair of dates. It often ends with a disclaimer that seems to take the answer back. Add your letter below to see each of those parts set out and explained.
Explain your prior authorization letter
- 1. Add itDrop a PDF, take a photo or paste the text.
- 2. Check itPersonal details are removed on your device. You approve what is sent.
- 3. Read itSummary, table of results, terms and questions to ask.
The explainer opens on its own page with no adverts and no outside scripts. Your file is read on your device and is never uploaded.
What you get
- The decision for each requested item as the letter states it: approved, partially approved, pended or denied.
- Each service with its procedure code and the number of visits, units or days the decision covers.
- The valid-from and valid-through dates, and any limits on provider or place of care, shown together.
- Questions to ask your insurer's member services or your doctor's office.
Words on a prior authorization letter
- Approved or authorizedThe insurer has agreed that the request meets its criteria, for the services, dates and provider listed
- Partially approved or modifiedSome of what was requested was agreed, such as fewer visits or a different setting
- PendedNo decision yet, usually because the insurer has asked for more information
- Denied or adverse determinationThe request was not agreed; the letter gives a reason and appeal information
- Authorization or reference numberThe insurer's identifier for this decision
- Valid from and valid through (or expiration date)The period in which the service has to take place for the decision to apply
- Units, visits or daysHow much of the service the decision covers
What this tool cannot tell you
MedicDecode explains the wording of the letter. It cannot see your plan, so it cannot say whether a decision is right, whether a service will be paid for, or what you will owe, and it does not give legal or financial advice. An approval is tied to the details printed on it, and only your insurer can confirm how those apply to you. For a pended or denied request, your doctor's office usually knows what was sent and what the insurer asked for.
Common questions
My letter says approved but also not a guarantee of payment. What does that mean?
The two statements cover different things. The approval refers to the insurer's review of the request, and the disclaimer says payment still depends on other conditions in the plan, such as being covered on the date of service. MedicDecode cannot tell you how those conditions apply, so ask member services what else payment depends on.
What does pended mean?
It means the request is on hold and no decision has been made. Letters that use the word normally say what is missing, who has been asked for it and by when. The explanation lists those details where the letter gives them.
What is the authorization number used for?
It is the insurer's reference for this particular decision. The insurer and the provider's office use it to find the decision, and the provider may need to quote it when billing. Keep the letter with your records so you can give the number if asked.
Words you may see on this report
Tap a word for its plain-English meaning, an example line and what it does not mean.
- Prior Authorization
Prior authorization is approval your insurer must give before certain treatments, tests or medicines are covered.
- Coinsurance
Coinsurance is the percentage of a covered health care cost you pay after meeting your deductible, such as 20 percent of the allowed amount.
- Copay
A copay is a fixed amount you pay for a covered health service or prescription, such as a set fee for each doctor visit.
- CPT Code
A CPT code is a five-character code that describes a medical service or procedure, used on bills and insurance claims in the United States.
- Deductible
A deductible is the amount you pay for covered health care each year before your insurance starts paying its share.
- Explanation of Benefits (EOB)
An explanation of benefits (EOB) is a statement from your insurer showing what was billed, what the plan paid and what you may owe for a claim.
- ICD-10 Code
An ICD-10 code is a letter-and-number code that describes a diagnosis, symptom or reason for care on medical records and bills.
- In-Network
In-network means a doctor, hospital or pharmacy has a contract with your insurance plan to provide care at agreed prices.
- Out-of-Pocket Maximum
The out-of-pocket maximum is the most you pay for covered, in-network care in a plan year; after that, the plan pays 100 percent of covered services.