Prior Authorization
Approval your health insurer requires before it will pay for certain treatments, procedures, or medications — obtained before the care happens, not after.
Actuarial & Contractual Mechanics
Prior authorization exists so insurers can review whether a specific treatment meets their medical necessity criteria before agreeing to pay for it, and it's most commonly required for expensive procedures (like bariatric surgery), higher levels of mental health care (like inpatient or residential treatment), certain specialty medications (including many GLP-1 weight-loss drugs), and imaging like MRIs or CT scans. The request is typically submitted by your provider's office, not by you directly, but the outcome directly affects your wallet: skipping a required prior authorization is one of the most common reasons an otherwise legitimate claim gets denied outright, regardless of whether the care itself was medically appropriate.
Before scheduling bariatric surgery, Elena's surgeon's office submits a prior authorization request documenting her BMI, comorbidities, and prior weight-loss attempts. The insurer approves it in advance, confirming the surgery will be covered before Elena undergoes the procedure — if the office had skipped this step, the claim could have been denied afterward even though Elena met all the medical criteria.
A denied prior authorization isn't necessarily the final word — most plans have a formal appeals process, and getting the plan's specific written medical policy criteria (not just the denial letter) is usually the fastest way to understand what additional documentation could change the outcome. See does health insurance cover weight loss drugs or bariatric surgery? and does health insurance cover therapy and mental health treatment? for two of the most common real-world prior authorization scenarios.
Prior authorization is one of the most common reasons an otherwise medically appropriate claim gets denied — not because the care was wrong, but because a required approval step was skipped.
What Actually Requires Prior Authorization
Insurers typically require prior authorization for expensive or higher-risk categories of care: major surgeries like bariatric procedures, higher levels of mental health treatment such as inpatient or residential care, certain specialty medications including many GLP-1 weight-loss drugs, and advanced imaging like MRIs and CT scans. The request is almost always submitted by the treating provider's office, not the patient directly, and reviewed against the insurer's specific written medical necessity criteria before treatment happens.
Why Skipping It Is So Costly
A missing prior authorization is a procedural failure, separate from whether the underlying care was medically necessary — which is exactly why it can result in a full claim denial even for entirely appropriate treatment. See does health insurance cover weight loss drugs or bariatric surgery? and does health insurance cover therapy and mental health treatment? for two of the most common real-world scenarios where this comes up.
Ask your insurer for their specific written medical policy criteria for that treatment, not just the denial letter — it's usually the fastest way to see exactly what documentation an appeal would need.
Frequently Asked Questions About Prior Authorization
Clear definitions, policy implications, and related coverage calculators.