Prior authorization

Prior authorization is a rule your health plan applies before it agrees to pay. Your prescriber submits a request, the plan reviews it against its own criteria, and coverage only begins once the plan approves.

It is worth separating two things that often get confused. Prior authorization is a coverage decision, not a clinical one. A denial does not mean the treatment is wrong for you — it means the plan has not agreed to pay for it under its current rules. Your prescriber can still consider it appropriate, and you can appeal.

What usually moves it along

• Ask the prescribing office whether the request has actually been submitted, and on what date.
• Ask which criteria the plan is applying, since those are what the paperwork has to satisfy.
• Ask whether the plan offers an expedited review — most do where a delay would cause harm.
• Keep the reference number for the request. Every follow-up call will ask for it.

If the request is denied, that is not the end of the process. See coverage appeal.