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.