Do I Need Prior Authorization? – A Step-by-Step Guide

Ever heard the term “prior authorization” and wondered what it actually means? If you're planning a medical procedure, getting a new prescription, or seeing a specialist, this is something you might run into. But don’t worry — we’ve got you covered!

What Is Prior Authorization?

Prior authorization (also called pre-authorization or pre-certification) is when your health insurance plan requires your doctor to get approval before your plan will cover a specific service, medication, or piece of equipment.

It’s basically your health insurance company’s way of making sure a treatment is medically necessary and cost-effective.

Common Services That May Need Prior Authorization:

• Certain prescription medications (especially specialty drugs)

• Imaging tests (MRI, CT scans, PET scans)

• Surgeries and outpatient procedures

• Physical therapy or rehabilitation

• Durable medical equipment (like CPAP machines or wheelchairs)

• Some specialist visits

  
  

How to Know If You Need Prior Authorization:

1: Check Your Plan Documents Your health insurance plan’s Summary of Benefits and Coverage (SBC) or Evidence of Coverage (EOC) should list which services require prior authorization.

Step 2: Ask Your Doctor’s Office Doctors’ offices usually know which procedures need prior authorization — and in most cases, they’ll handle the request for you!

Step 3: Call Your Insurance Company If you’re unsure, call the customer service number on your insurance card. They can tell you if prior authorization is needed for your specific service or medication.

What Happens Next?

• If approved, your health insurance will cover the service (subject to your deductible, copay, or coinsurance).

• If denied, you or your doctor can file an appeal.

  
  

Why Does It Matter?

Skipping prior authorization can cost you! If you get a service that needed prior authorization but didn’t get it, your health insurance may refuse to pay — leaving you with the full bill.

Quick Tips:

✅ Always double-check if prior authorization is needed — especially for high-cost services. ✅ Give your doctor’s office time to submit the request (it can take days or even weeks for approval). ✅ Keep copies of approval letters for your records.

Bottom Line: Prior authorization is a key part of using your health insurance wisely. A little planning upfront can save you stress and big bills later.

Have questions about how your plan works? We’re happy to help — reach out anytime!