Answer
What is prior authorization, and what does approval actually mean?
The short answer
Prior authorization is when your plan reviews certain care before you get it. Approval means the plan agrees the care meets its rules at that time. It does not guarantee payment. The plan still checks your coverage, network, and the claim details after the care.
Key takeaways
- Your provider usually requests prior authorization, but you can ask about its status.
- An approval may cover specific dates, services, places, or numbers of visits.
- If a request is denied, you can usually appeal. Urgent requests can be reviewed faster.
Words in this lesson
- Prior authorization
- Your plan's approval before certain care. Approval is not a guarantee of payment.
- Medically necessary
- Care your plan agrees is needed to diagnose or treat a health condition, based on its rules. Plans may deny care they consider not medically necessary.
- Appeal
- A formal request asking your plan to review and change a decision, such as a denied claim or prior authorization.
- Expedited (urgent) appeal
- A faster review when waiting for a standard decision could seriously harm your health.
Related
This is general education. For decisions about your own plan, taxes, or legal rights, check your plan documents or a qualified professional.