Pre-Authorization Definition

Pre-Authorization, also known as prior authorization or prior approval, is a process used by health insurance companies to determine whether a proposed medical service, treatment, or prescription medication is medically necessary and eligible for coverage before it is provided to the patient. This process involves the healthcare provider submitting a request to the insurance company, which reviews the request based on established clinical criteria and coverage policies. The purpose of pre-authorization is to control healthcare costs and ensure that patients receive appropriate and effective care.

Services that often require pre-authorization include certain surgeries, advanced imaging studies (like MRI or CT scans), specialized treatments, and some prescription drugs. Failure to obtain pre-authorization when required can result in denial of coverage, meaning the patient may be responsible for the full cost of the service. It is essential for both patients and healthcare providers to understand and comply with pre-authorization requirements to avoid unexpected expenses and ensure timely access to necessary medical care.