An insurance company often requires this type of preapproval for certain services, procedures, prescription medications, and medical supplies. Your healthcare team can often help you navigate this process.

You may get a prescription or medical service order from your doctor, but an insurance company may not initially approve it.

Instead, the insurer may require what’s known as prior authorization. This is a commonly used method an insurance company uses to get approval before you receive the medical services or prescriptions.

This may lead to delays, and your healthcare team may need to take time to submit documentation showing why there’s a medical need for the specific item, using their clinical expertise and medical guidelines. They may also communicate with your insurance company about specific details on how a service or prescription is covered.

Prior authorization (PA) allows your insurance company to review the proposed treatment, procedure, or medication to determine if it is medically necessary and covered under your plan’s benefits.

If a service or drug requires prior authorization and you receive it without the insurer’s approval, your health plan may not cover your treatment, leaving you responsible for the full cost.

  • Who handles a PA request? Usually, your doctor or healthcare team will handle this process, and you may not know it’s happened until after the fact. They will typically submit any necessary paperwork and clinical documentation to the insurer, showing why a particular prescription or medical service is needed.
  • Why is this required? A prior authorization is the insurer’s way of determining that something your doctor orders is actually necessary and is in line with medical standards and guidelines while managing the high costs of healthcare.
  • How long does a PA take? The insurer reviews the submitted information against its coverage policies and clinical criteria. They may approve the request, deny it, or request more information. There is no standard timeline for this process, but an insurance company typically has a procedure that it follows and outlines in your plan documentation.
  • What healthcare is affected? Prior authorization is typically required for higher-cost items, complex treatments, or those with lower cost alternatives available. This may include:
    • diagnostic or imaging tests (like MRI, CT, or PET scans)
    • procedures and surgeries
    • specialty or brand-name medications
    • inpatient hospital stays
    • durable medical equipment, such as insulin pumps or continuous glucose monitors (CGM)
  • Does this affect emergency care? No, emergency medical services does not generally require prior authorization.

Clinical research and surveys of medical professionals generally agree that prior authorization, while intended for cost management and ensuring appropriate care, frequently introduces several negative consequences for people’s healthcare.

  • Delays and access barriers: The time required for an insurer to review and approve a request can delay the start of critical treatment, which can lead to worse health outcomes. A 2024 survey by the American Medical Association (AMA) found that 93% of physicians they asked about PAs found some delay in care. The survey also found 82% responded that at times, their patients abandoned a particular treatment or care because of the PA.
  • Negative health effects: Aside from delays, the AMA survey also found that 1 in 4 physicians reported a patient experienced an adverse event (ranging from hospitalization to other possible life threatening effects) because of the PA process.
  • Forced alternatives: People who are denied initial coverage are commonly forced to receive second-choice options, something known as non-medical switching. This can include treatments that are less effective or have a higher risk for toxicity, affecting patient-centric outcomes.
  • Condition-specific harm: Some research has noted specific harm, such as treatment delays for cancer patients, where a prolonged wait for radiation therapy is associated with an increased risk of cancer progression, complications, and death.

If your health insurance company does not provide prior authorization and denies a claim, you and your doctor’s office do have ways to appeal that decision.

The time a doctor’s office and staff spend on administrative tasks related to PA directly reduces the time and resources available for direct patient care.

In the AMA survey, practices report spending the equivalent of many hours per week on non-clinical prior authorization tasks, diverting valuable time away from patient engagement and clinical work.

Physicians and healthcare professionals also report burnout and extra administrative costs tied to insurance requirements, including prior authorizations.

The AMA has stated that it believes prior authorizations are “overused,” and that “existing processes present significant administrative and clinical concerns.”

An insurance company often requires this type of preapproval for certain services, procedures, prescription medications, and medical supplies. Your healthcare team can often help you navigate this process.