Why Prior Authorization Matters

Your healthcare provider recommends a medical test or procedure, but before you can schedule it, your health plan may require one more step: prior authorization.

Prior authorization is a process some health insurance plans use to determine whether certain medications, imaging tests, procedures, or medical services meet the plan’s coverage requirements before they are provided. While not every service requires prior authorization, many plans use it for higher-cost services or treatments.

The purpose of prior authorization is to help ensure that care is medically appropriate and consistent with a health plan’s guidelines. Requirements vary by insurance carrier and health plan, which means a service that requires prior authorization under one plan may not require it under another.

One common misconception is that if a healthcare provider recommends a service, it is automatically covered by insurance. Provider recommendations and insurance coverage decisions are separate. Even experienced healthcare providers may not know the specific requirements of every health plan.

For example, one individual was referred by their doctor for an MRI and was told that prior authorization was not required. Before scheduling the appointment, they asked the imaging department to confirm whether authorization was needed. After reviewing the member’s insurance card, staff said no prior authorization was required. The individual still had concerns and called the number on the back of their ID card to verify. They were correct. Prior authorization was required for the MRI. Taking a few extra minutes to confirm the requirement helped avoid a claim denial and a potential bill of more than $3,000.

This experience clearly shows that asking questions can help prevent delays, denials, and unexpected expenses.

Before scheduling a procedure, imaging test, or specialty service, consider asking:

• Does this service require prior authorization under my health plan?
• Has authorization already been requested and approved?
• Are the provider and facility in-network?
• What are my estimated out-of-pocket costs?
• Are there any steps I should take before receiving care?

While prior authorization can sometimes delay care, understanding the process and confirming requirements ahead of time can help make the experience smoother.

Being an informed healthcare consumer does not mean knowing every insurance rule. It means asking questions, understanding your benefits, and taking an active role in your healthcare decisions. A few minutes of preparation before receiving care may help save both time and unexpected expenses later.

Prior authorization requirements vary by insurance carrier and health plan. Members should review their plan documents and confirm coverage requirements before receiving services.