Prior Authorization

Prior authorization is a requirement from your health plan that the provider get approval before performing certain services, or the claim won't be paid. It's used to enforce medical necessity criteria on higher-cost items — MRIs, most surgeries, specialty drugs, inpatient admissions, PT beyond a certain number of visits.

The process usually runs like this: the provider's office submits clinical documentation to the plan (or the plan's utilization management vendor), the plan reviews it against internal criteria, and approves, denies, or asks for more information. Turnaround ranges from same-day for standard requests to 72 hours for urgent to two weeks for non-urgent — and delays are common. When a claim is submitted without prior auth on a service that required it, the plan denies the whole claim and the provider (or the patient) eats the cost. Prior auth is one of the most contentious pieces of the system — providers hate the friction, plans use it to control spend, and patients get caught in the middle. Some state laws (Texas SB 1742 is one) now require faster turnaround and gold-carding for providers with high approval rates.

The takeaway: before any scheduled MRI, surgery, or specialty medication, ask "does this need prior authorization, and is it approved?" Get the auth number in writing before the appointment.