Pre-authorization (also called "prior authorization" or "pre-certification") is approval you need to get from your benefits administrator or insurance company before receiving certain medical services or procedures. This process ensures the service is medically necessary and covered under your plan before you receive treatment.
Why pre-authorization exists
Pre-authorization helps control costs and ensures appropriate care. It's typically required for expensive procedures, surgeries, hospital admissions, certain specialist referrals, and high-cost diagnostic tests. The process involves your doctor submitting medical information to justify why the treatment is needed. Without pre-authorization, your claim may be denied or only partially covered, leaving you responsible for the full cost.
How pre-authorization works in the industry
In traditional insurance, pre-authorization is common for:
- Major surgeries and procedures
- Hospital admissions (especially for non-emergency care)
- Expensive diagnostic tests (like MRIs, CT scans)
- Specialist referrals (in some plans)
- Certain medications or treatments
The process usually involves your doctor submitting medical records, test results, and a treatment plan. Approval can take anywhere from a few days to a few weeks, depending on the complexity.