Insurance pre-authorization

Insurance pre-authorization is an insurer’s formal approval required before certain medical services, tests, or prescriptions will be covered. Health plans like UnitedHealthcare and Cigna require pre-authorization for high-cost procedures such as MRIs, CT scans, and some surgeries.

Patients who skip pre-authorization risk claim denials, as shown by a 2022 AMA survey indicating 94% of physicians reported delays or denials due to pre-authorization issues. Most insurers process pre-authorization requests in one to five business days for non-urgent care and less than 24 hours for urgent care.

Hospitals and clinics submit pre-authorization forms with patient records, diagnosis codes, and doctor’s recommendations to insurers via electronic portals or fax. Insurers deny pre-authorization if treatments are not medically necessary per their evidence-based guidelines, with Aetna data showing about 1 in 7 pre-authorizations denied in 2020.

Patients may appeal denied authorizations through internal insurer review or external state regulatory boards, citing documentation like physician letters or peer-reviewed studies. Pre-authorized approvals remain valid only for specific time frames stated by the insurer–often 30–90 days–after which re-approval is needed, as recorded by YourInsurance.info.

Insurance cards list customer service phone numbers for confirming if pre-authorization applies before scheduling care. Medicare and Medicaid also enforce prior authorization on durable medical equipment and some specialty drugs to limit unnecessary spending, with CMS reporting $3 billion saved in 2019 through these controls.

Doctors’ offices often use specialized staff called utilization review coordinators to track and manage all patient pre-authorizations for compliance and timely treatment access.