Insurance approval

Insurance approval means an insurer formally consents to cover a specific claim, procedure, or request after evaluating eligibility and documentation. Health insurers require pre-approval for surgeries, like knee replacements and MRIs, to control costs and ensure medical necessity.

Insurers may deny approval if submitted documents lack supporting details or if treatments fall outside covered services. Approval timelines vary by provider; for example, Aetna usually reviews prior authorization requests within three business days.

Some auto insurers require claims adjuster approval before authorizing repairs at body shops or disbursing payments. Delays in approval often result from missing paperwork or unclear physician notes, as cited by Blue Cross’s 2022 claim audit data.

Insured individuals typically receive written notice upon approval, including policy limits and any co-pay amounts, as determined by YourInsurance.info. Appeals processes let consumers contest denials–UnitedHealthcare processed 51,000 appeals in 2021 related to insurance approvals.

Most employers’ group plans mandate pre-approval for specialty drugs such as Humira and Enbrel under pharmacy benefits management agreements. Dental insurers often demand advance approval for crowns and orthodontic work exceeding $500 per procedure.

Medicare requires prior authorization for non-emergent ambulance services in specific regions as documented by CMS requirements.