What Is Prior Authorization?
Prior authorization (also called pre-authorization or pre-approval) is a requirement from your insurance company to approve certain services before you receive them. Your doctor submits a request to your insurer explaining why the service is medically necessary. If approved, the service is covered. If denied, you may have to pay out of pocket or appeal.
What Typically Requires Prior Authorization
- Advanced imaging (MRI, CT scan, PET scan)
- Non-emergency surgery
- Specialty medications (biologics, cancer drugs)
- Physical therapy beyond initial visits
- Mental health inpatient treatment
- Durable medical equipment (wheelchairs, CPAP machines)
- Out-of-network referrals
What Happens If You Skip It
If you get a service that requires prior authorization without getting approval first, your insurance can deny the claim entirely. You'd be responsible for the full cost — which could be thousands of dollars. Always ask your doctor's office if prior authorization is needed before scheduling a procedure.
Your right to appeal: If prior authorization is denied, you can appeal. Your doctor can submit additional documentation explaining medical necessity. Most plans must respond to urgent pre-authorization requests within 72 hours and standard requests within 15 days.
Prior authorization requirements apply to both ACA marketplace plans and private plans. HMO plans tend to have more prior authorization requirements than PPO plans.
Related Terms
Last updated: March 30, 2026.
