Preauthorization

A Basic Explanation

Before you can schedule certain healthcare services you may need to get preapproval from your insurance company. This is called preauthorization. (The terms precertification, prior authorization, and prior approval are also used, and they all basically mean the same thing.) Your carrier may ask for details such as your diagnosis, why you need the service, and where you are getting the service before giving you the green light. By preauthorizing a service, treatment plan, or procedure, your insurance carrier is agreeing that the healthcare recommended is medically necessary.

Expert Advice About Preauthorization

Most basic medical needs, such as a trip to your primary care doctor or urgent care center, don’t need preauthorization. But things like medical tests, some prescriptions, and many types of medical equipment often do. Common procedures and services that typically need preapproval include:

  • Gastrointestinal tests (endoscopies, colonoscopies)
  • Home care services (home therapy, hospice, skilled nursing visits)
  • Pain management services (nerve blocks, trigger point injections, etc.)
  • Radiology services (X-rays, CT scans, ultrasounds)
  • Sleep studies (to diagnose sleep disorders)
  • Surgical procedures
  • Non-emergency ambulance services
  • Specialty drugs provided in certain situations
  • Durable medical equipment
  • Inpatient hospital services (you’ll need a special type of preauthorization, called “preadmission certification,” for these services.)

Get familiar with some of the services that require preauthorization. Most plans will ask for preauthorization for at least some services. The list of which ones require preapproval will vary, depending on your insurance company and your plan, so it never hurts to double-check everything beyond routine care ahead of time. Also keep in mind that insurance companies may not precertify a visit to a medical provider who’s out of your network.

Don’t skip preauthorization if it’s required. If you go ahead and schedule a service without getting clearance, your claim may be rejected. You could get stuck with the entire bill for an expensive medical procedure if your carrier decides they aren’t going to pay.

Just so you’re crystal clear on what is being preapproved, ask your insurance company these additional questions:

  • How many visits are approved?
  • Do I need a new approval for each visit?
  • If I’m going to be hospitalized or use inpatient care, how many days am I allowed to stay?

Check to make sure the preauthorization paperwork is completed. The doctor’s office or treatment facility you’re going to will usually requst preauthorization and provide the necessary medical information to your insurance company. But before you go for the service, test, or treatment, it’s a good idea to call the provider’s office to make sure all the paperwork was attended to. You know, the i’s dotted and the t’s crossed. (Of course you can always submit a corrected claim and file an appeal if it’s rejected. But who needs the hassle?)

What Else You Need to Know

  • Preauthorization doesn’t guarantee your health insurance will cover the cost. For example, if you haven’t met your annual deductible yet, your insurance may not kick in to help pay for a preauthorized service. But at least what you pay will be based on rates your insurer has negotiated. Plus it will count toward meeting your deductible.
  • In a medical emergency, preauthorization is not required. The Affordable Care Act (ACA) states that qualified health plans can’t require preauthorization for medical emergencies. So if an emergency arises, you can head to the ER without worrying about whether you’ll be covered. (Even if the health provider or hospital is out of network, your insurance carrier can only charge you in-network copays and coinsurance rates rates for emergency care.)