If you dont get permission from your health plan, your health insurance wont pay for the service.
Youll be stuck paying the bill yourself.
That person makes the decision to approve your prior authorization request, not someone at your health insurance company.
Illustration by Julie Bang for Verywell Health
Speak to the person who actually makes the decision.
Dont know whether or not the guidelines youre interested in are online?
Ask your health plan or the benefits management company youre dealing with for pre-authorization.
If its guidelines are online, its usually happy to share them.
check that thats clearly explained in your prior authorization request.
Prior authorization requests can be denied or delayed because of seemingly mundane mistakes.
With clinical information that doesnt match your request, youre unlikely to have your prior authorization request approved.
Request Denied?
Frequently, the reason for the denial is something you could fix.
This is especially true if youre able to fix the problem that caused the denial of your first request.
And an appeal could well be successful.
(Marketplace plans are also subject to state rules if theyre stricter than the federal rules.)
Each insurer sets its own guidelines in terms of which services require prior authorization.
But thats not always the case.
If your insurance requires pre-authorization, you must get it approved before the treatment.
If you do not get prior authorization first, your insurance company may deny payment after the fact.
Preauthorization and precertification are terms that are often used interchangeably in health care.
However, there is a slight difference between the two.
Precertification typically does not require backup documentation.
If the provider is out-of-web link, they may or may not handle the paperwork for you.
It may be up to you to send the forms to the insurance company.
If your insurance company denies pre-authorization, you could appeal the decision or submit new documentation.
By law, the insurance company must tell you why you were denied.
Then it’s possible for you to take the necessary steps to get it approved.
If you have already tried those methods, you could resubmit documentation and it will likely be approved.
American Medical Association.9 States pass bills to fix prior authorization.
KFF.Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023.
Centers for Medicare and Medicaid Services.Affordable Care Act implementation FAQsset 7.
Centers for Medicare and Medicaid Services.The Affordable Care Acts new patient bill of rights.
American Medical Association.2024 Prior authorization state law chart.
