Prior authorization, and how to get one

Prior authorization means the insurer must approve a service before it is provided, or coverage may be denied afterward.

It applies to a growing range of services: imaging, surgery, specialty drugs, durable medical equipment, inpatient admissions, certain therapies.

How the process works

The provider submits a request with clinical documentation. The insurer reviews it against internal criteria. A determination is issued, sometimes within days and sometimes considerably longer.

Reviews are conducted initially by staff applying criteria, with denials on medical necessity grounds generally requiring review by a clinician.

Approval is typically valid for a defined period and for a specified quantity or number of visits.

Why requests get denied

The reasons are more often procedural than clinical, which is useful to know because procedural problems are fixable.

Insufficient documentation. The most common. The clinical record submitted did not demonstrate what the criteria require.

Step therapy not completed. The plan requires trying a preferred treatment first — commonly a less expensive drug — before covering the requested one.

Criteria not met. The clinical situation does not match the insurer's medical policy for that service.

Wrong codes. A diagnosis or procedure code that does not support the request.

Considered experimental or investigational, per the insurer's technology assessment.

Not a covered benefit, which is a different category entirely and is contractual rather than clinical.

Improving the odds before submission

Get the insurer's medical policy. Most publish their coverage criteria online. Find the policy for the specific service and read the criteria.

Then make sure your clinical documentation addresses each criterion explicitly. This is the single most effective thing you can do.

Ensure the documentation includes the history. Prior treatments tried, their outcomes, why they failed or were inappropriate. Conservative measures attempted. Duration and severity of symptoms.

Denials frequently occur because the record contains the information in the physician's head but not in the submitted notes.

Check the codes. A mismatch between the diagnosis code and the procedure code produces automatic denials.

Submit early. Standard review timelines can run to a couple of weeks, and appeals extend it further.

Expedited review

Where a delay would seriously jeopardize health or the ability to regain function, an expedited review can be requested, with a much shorter decision timeline.

This must generally be requested explicitly and supported by the physician.

Do not assume urgency is apparent from the request. Say it, and have the physician document why.

When it is denied

Get the denial in writing, with the specific reason and the criteria applied.

A verbal denial is not something you can appeal against effectively. The written notice must generally state the basis and the appeal rights.

Request a peer-to-peer review. Your physician speaks directly with the insurer's reviewing clinician.

This is frequently the fastest route to reversal, because it allows clinical nuance that a form cannot convey. A meaningful proportion of denials are overturned at this stage.

Physicians are often willing to do this if asked directly.

File an internal appeal. A formal request for reconsideration, with additional documentation.

Address the stated reason specifically. If the denial says step therapy was not completed, provide the record of prior treatment. If it says criteria were not met, provide documentation of each criterion.

A generic letter asking for reconsideration achieves little.

Request an external review. Where internal appeals are exhausted, most plans are subject to independent external review by a reviewer not employed by the insurer.

This is a genuine right under federal and state law for most plans, and external reviewers overturn a meaningful share of denials.

The decision is generally binding on the insurer.

Documentation throughout

Keep a record of every call: date, time, representative name, reference number, what was said.

Keep copies of everything submitted and received.

Get any verbal approval confirmed in writing. Verbal assurances from call center staff have very limited value in a dispute.

The retroactive denial problem

Worth knowing: an authorization is not always a guarantee of payment.

Many authorization notices state that approval is not a guarantee, and payment remains subject to eligibility, benefit limits and post-service review.

This is genuinely unfair and it is what the documents say. Keep the authorization; it is strong evidence in any subsequent dispute.

Where to escalate

If the process stalls, your state department of insurance accepts complaints, and for employer plans the federal Department of Labor has jurisdiction over many self-funded plans.

Insurers respond to regulator inquiries differently than to member calls.

General information about insurance processes, not insurance, legal or medical advice. Appeal rights and timelines vary by plan type and state. Consult your policy documents, your insurer and your state insurance department.