Prepare before care · Lesson 6 of 16
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.
Prior authorization, also called pre-approval or pre-certification, is a check before care. Plans use it for some tests, surgeries, medicines, and ongoing therapies.
Who does what
Your provider usually sends the request with medical details. The plan reviews whether the care is covered and medically necessary under its rules. You may get a letter with the decision.
Why approval is not a promise
An approval says the plan agreed in advance. The claim is still reviewed later. Payment can still be reduced or denied if, for example:
- your coverage ended before the care date,
- the care was different from what was approved,
- it happened after the approval expired or at a different place,
- the provider was out of network, or
- you have not met your deductible, so you still owe your share.
Read the approval for dates, codes, number of visits, and the facility. If anything changes, ask the provider to update the approval.
Decision times
For employer plans covered by federal law, non-urgent pre-service decisions must be made within 15 days, and urgent ones within 72 hours.[1] Federal rules for some Medicare Advantage, Medicaid, and Marketplace plans set new decision timeframes starting in 2026.[2]
If it is denied
A prior authorization denial is a pre-service decision. You can usually Appeal it. If waiting could seriously harm your health, ask for an expedited appeal.[3] Your clinician can often help by sending more information or asking to speak with the plan's reviewer.
What can be different for you
Each plan keeps its own list of services that need prior authorization. Original Medicare uses it for fewer services than most Medicare Advantage plans. Medicaid rules vary by state. Some states have extra rules about prior authorization timing for state-regulated plans.
More detail (optional)
Peer-to-peer review
Some plans let your clinician speak directly with the plan's medical reviewer about a denial. Ask your clinician if this is an option.
Changing plans
A prior authorization from one plan does not carry over to a new plan. If you change plans, ask your new plan how to continue ongoing care.
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
Where can I go for help?
Free help is often close by: the member services number on your insurance card, the billing office for your provider, your state insurance department, and nonprofit patient advocates.
This is general education. For decisions about your own plan, taxes, or legal rights, check your plan documents or a qualified professional.