Prior authorization is a health plan requirement that a healthcare provider get approval before delivering certain services, procedures or medications for the plan to cover them. The provider’s office submits clinical documentation showing medical necessity, and the insurance company approves, denies or asks for more information. For practices, it is one of the most time-consuming administrative tasks.
Key takeaways
- Prior authorization, also called pre-authorization or precertification, is how insurance companies check medical necessity and control costs before care is delivered.
- The healthcare provider’s office, not the patient, is responsible for submitting the prior authorization request.
- Most delays and denials come from incomplete documentation, missed plan rules or skipped steps such as step therapy.
- Denials are often overturned on appeal. In Medicare Advantage, about 8 in 10 appealed denials were overturned in 2024.
- A repeatable workflow, clear ownership and one place to track every request make the biggest difference.
What is prior authorization in healthcare?
Prior authorization is a check that a health plan covers a proposed service, procedure or medication before the patient receives it. The provider sends the patient’s clinical information to the health insurance company, which reviews it against its coverage rules and clinical criteria.
Insurance companies use prior authorization to control costs and confirm that care is medically necessary. They also use it to steer patients toward lower-cost options when several treatments work, and to catch duplicate or inappropriate services.
For practices, the reality is a heavy workload. In an AMA survey of 1,000 physicians in late 2024, practices completed an average of 39 prior authorization requests per physician each week, and physicians and their staff spent about 13 hours a week on them.
Prior authorization at a glance
| Component | Description |
|---|---|
| Primary goal | To manage healthcare costs and confirm medical necessity before services are delivered |
| Key players | The patient (who needs the care), the provider (who requests approval) and the payer (the health insurance company that approves or denies) |
| Common triggers | Brand name medications, advanced imaging such as MRIs and CT scans, planned surgeries and many procedures, durable medical equipment, behavioral health services and specialized therapies |
| Possible outcomes | Approved (care proceeds), denied (care is not covered unless appealed) or more information needed (the review is paused until the practice responds) |
Prior authorization vs pre-authorization
The terms mean the same thing. Prior authorization, pre-authorization, preauthorization and precertification are used interchangeably by different insurance providers. Some health plan documents also use “pre-service review.”
Who is responsible for obtaining prior authorization?
The healthcare provider’s office is responsible. The patient provides current insurance information, but the practice’s clinical and administrative staff gather the documentation, complete the payer’s forms and submit the request. Many practices have staff who work only on prior authorizations: in the same AMA survey, 40% of physicians said they do.
How does the prior authorization process work?
The prior authorization process usually follows six steps. Take a common example: a patient with persistent joint pain needs an MRI.
1. Check whether the service requires prior authorization
As soon as the provider orders the MRI, staff confirm the patient’s current insurance plan and check whether that plan requires prior authorization for this specific service. Requirements vary by plan type, payer and service, so this step should happen before the patient is scheduled. Skipping it is one of the most common causes of a denial.
2. Gather clinical documentation
Staff assemble the evidence that shows medical necessity under the payer’s criteria. For the MRI, that means notes on the severity and duration of the pain, a record of earlier treatments such as physical therapy, and the provider’s explanation of why imaging is the next step. Incomplete documentation is the biggest single source of delays.
3. Submit the prior authorization request
The request goes to the payer through its portal, an electronic prior authorization connection, or in some cases fax or phone. Electronic submission is usually faster and easier to track.
4. Track the request and respond to payer requests
While the insurance company reviews the request, staff track its status and respond quickly if the payer asks for additional information. Requests that sit untouched in a queue are a common cause of care delays.
5. Receive the decision
The payer approves, denies or asks for more information. Under the CMS Interoperability and Prior Authorization Final Rule, many payers, including Medicare Advantage plans and Medicaid programs, must now respond within 72 hours for urgent requests and seven calendar days for standard requests.
6. Act on the outcome
If approved, staff schedule the service and note the authorization details, including its expiry date. If denied, the practice decides whether to correct and resubmit or appeal. In both cases, staff tell the patient what happens next.
What is step therapy?
Many plans, especially for medications, require step therapy: the patient must try a lower-cost treatment first. If the request does not document that the earlier treatment was tried and failed, or why it is not appropriate, the request for the more expensive option is likely to be denied.
Why are prior authorizations delayed or denied?
Most prior authorization denials are not about the care itself. They usually come from preventable process problems:
- Missing clinical evidence: The request lacks the chart notes, imaging reports or treatment history that show medical necessity.
- Plan rules not followed: The service needed authorization and none was requested, or the request went through the wrong channel.
- Skipped step therapy: A required lower-cost treatment was not tried or not documented.
- Mismatched request details: The service requested does not match the documentation, or patient details such as the plan number are wrong.
- Out-of-network care: The provider or facility is not in network for the patient’s plan.
- Expired authorizations: The service was delivered after the approval period ended.
The scale of the problem
A KFF analysis of Medicare Advantage data found that insurers made nearly 53 million prior authorization determinations in 2024 and fully or partially denied 4.1 million of them (7.7%). Only 11.5% of denied requests were appealed, but 80.7% of those appeals overturned the initial denial. In other words, many denials do not hold up, yet most are not challenged.
Prior authorization best practices for medical practices
The practices that handle prior authorization well do not rely on memory. They build a repeatable workflow:
- Know which services require prior authorization. Keep a current list of the services and medications that need authorization for your most common plans, and update it when payers change their rules.
- Check requirements at scheduling. Confirm the patient’s plan and authorization needs when the appointment is booked, not the day before.
- Use documentation checklists. For your 10 to 15 most common requests, list exactly what each payer needs, so staff can assemble a complete request the first time.
- Give every request an owner. One person owns each request, with a backup. Shared responsibility is how requests get lost.
- Track everything in one place. Log the date submitted, reference number, documents sent, expected response date and expiry date.
- Keep patients informed. Tell patients when the request is submitted, how long it usually takes and who to contact. This reduces follow-up calls.
- Review denials regularly. Look for patterns by payer and service, then fix the step in your workflow that caused them.
How to appeal a prior authorization denial
A denial is often the start of an appeal process, not the end of the case. A clear, consistent approach improves the odds:
- Read the denial reason quickly. Review every denial within one business day and note the exact reason and the appeal deadline.
- Decide the next step. Administrative denials, such as missing information, can often be corrected and resubmitted. Clinical denials usually need an appeal with physician input.
- Build a focused appeal packet. Include the denial notice, the payer’s criteria, the specific chart notes that meet them, the treatment history and a short letter of medical necessity from the treating physician. Answer the stated reason directly.
- Prepare for peer-to-peer reviews. Give the physician a one-page brief with the denial reason, the payer’s standard and the strongest clinical facts before the call.
- Escalate when needed. If the internal appeal fails, many plans allow an external review by an independent organization.
- Save what works. Keep successful appeal letters and arguments by payer and denial type, so the next appeal is faster.
Where technology helps
Prior authorization software can check requirements, assemble documentation, submit requests electronically and track status. Our guide to prior authorization software covers the categories and what to ask vendors.
A large share of prior authorization work also arrives by phone: patients asking about status, pharmacies calling about a medication and payers calling with updates. Simbie’s AI voice agents handle the phone side of prior authorization. They take prior auth requests and status calls from patients, pharmacies and payers, check the practice’s insurance rules when scheduling, and send each request to the practice’s prior authorization team as a task in the EHR. Simbie does not submit prior authorizations to payers.
Frequently asked questions
What is another name for prior authorization?
Prior authorization is also called pre-authorization, preauthorization, precertification or pre-service review. The terms mean the same thing.
How long does a prior authorization normally take?
It depends on the payer and the request. Under the CMS rule, many payers, including Medicare Advantage and Medicaid plans, must decide within 72 hours for urgent requests and seven calendar days for standard requests. Commercial plans vary, and incomplete requests take longer.
What happens if a prior authorization request is denied?
The practice can correct and resubmit the request or file an appeal. Many denials are overturned on appeal, especially when the appeal adds the clinical documentation the payer said was missing.
What happens after a prior authorization is approved?
The practice schedules the service, records the authorization number and dates, and makes sure the service happens before the approval expires. Some approvals cover a set number of visits or doses.
What happens if a service is delivered without prior authorization?
The health plan can refuse to cover it. That leaves the cost unresolved and can affect the patient, so practices should confirm requirements before non-emergency care.
Do you need prior authorization for emergency care?
No. Under the Affordable Care Act, most health plans cannot require prior authorization for emergency services. Prior authorization applies to planned, non-emergency care.
Can a patient submit their own prior authorization?
In most cases, no. The provider’s office submits the request because it requires the provider’s clinical documentation. Patients can help by keeping their insurance information current and contacting their plan if asked.
How do you explain prior authorization to a patient?
Keep it simple: “Your insurance plan needs to review and approve this service before it is covered. We send them your medical information, and we will let you know as soon as we hear back.” Tell the patient how long it usually takes and who to call with questions.
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