Prior authorization checklist for patients

Prior authorization, also called preauthorization or precertification, is an insurer’s approval for a service before you receive it. Plans use it for some tests, procedures, medications and specialist care. When it is required and missing, the claim can be denied, and the bill can land with you.

This checklist is general information. Your plan’s documents and your insurer decide which services need approval, how long it takes and what the approval covers.

Before you schedule

• Ask the doctor’s office whether the service needs prior authorization. Do not rely on the office alone, since requirements differ by plan.
• Check with the insurer. Call the member services number on your ID card, or look in the member portal or plan documents. Ask about the exact service, the facility and the provider you plan to use.
• Ask who submits the request. In most cases the provider’s office does, but confirm it.
• Ask for the details being submitted: the name of the service, the provider and facility, and the planned date range.
• Ask how long the review usually takes. Timelines vary, so schedule with that in mind.
• If your situation is urgent, tell both the office and the insurer, and ask about expedited review.

Once the request is submitted

• Ask the office for the date it was sent and any reference number. Write them down.
• Call the insurer a few days later to confirm it received the request and whether anything else is missing.
• If the insurer asks for more information, find out who must provide it and by when. A delay on that step can stall the whole review.
• Keep a log: date, who you spoke to, what they said.

When you get the decision

• Ask for the approval in writing, by mail or in the member portal.
• Read what it covers. Check the service, the provider, the facility, the dates and the number of visits or units.
• Compare it to what is actually scheduled. A change of doctor, facility, date or procedure may need a new or updated approval.
• Note the end date of the approval, and schedule before it expires.
• Remember that an approval is not necessarily a promise of payment. Your deductible, coinsurance and other plan terms can still apply, and your coverage has to be active on the day of service. Ask the insurer exactly what the approval does and does not guarantee.
• Save the approval and your notes with your other claim papers.

If the request is denied

• Read the denial for the reason and for the deadline to challenge it.
• Ask the doctor’s office whether they can submit more information or ask for a reconsideration. Some insurers offer a conversation between your doctor and the insurer’s reviewer.
• If that does not work, file an appeal. The steps are in appealing a denied claim.
• Do not schedule or delay urgent care just because the paperwork is unresolved. Talk to your doctor about what is safe to do while the review continues.

After the service

• When the explanation of benefits arrives, check that the claim was paid under the approval you got. How to read an EOB shows what to look for.
• Keep the approval until the final bill is settled.

Emergencies

In an emergency, get care first. Federal rules generally protect emergency care from needing prior approval, but your plan’s documents explain how your plan treats emergency visits and follow-up care. For any planned follow-up after an emergency, ask whether approval is needed.

Referrals are different

Some plans also require a referral from a primary care doctor before you see a specialist. That is a separate step from prior authorization. The Appointments and referrals section covers how referrals work and how to keep them from expiring.