Prior authorization

A requirement from the insurance company that a doctor obtain approval before prescribing certain medications, ordering certain tests, or providing certain treatments. The patient can't get the service until the PA clears. Denials are common; appeals usually succeed but take weeks.

What it means in practice

Prior authorization is the insurance industry's primary cost-control mechanism. The carrier requires the prescribing or ordering clinician to submit documentation justifying medical necessity before agreeing to pay. The clinician's office staff (often a dedicated prior-auth nurse) compiles the chart notes, lab results, prior treatments tried, and clinical rationale, submits via fax or portal, and waits. Standard PA turnarounds are 5-14 business days; expedited PAs for urgent care are 1-3 days. About 6% of PA requests are initially denied; 80%+ of appealed denials are eventually overturned.

The most-prior-authorized categories are specialty medications (biologics for RA, MS, IBD; cancer therapeutics; newer diabetes and weight-loss drugs), advanced imaging (MRI, CT, PET), surgical procedures (especially orthopedic and bariatric), and post-acute care (SNF stays, home health, DME above certain price thresholds). About 99% of Medicare Advantage enrollees are in plans that use PA for at least some services; original Medicare uses PA much less aggressively.

Family caregiver tactics that improve PA success: (1) ask the clinician's office if a PA is being submitted and the expected turnaround; (2) keep a record of all PA submissions and decisions; (3) when a denial happens, immediately request the written denial letter (it tells you the appeal deadline and the specific reason); (4) ask the clinician to file a peer-to-peer review (a doctor-to-doctor phone call that often resolves denials faster than written appeals); (5) for second-level appeals, contact your state's insurance commissioner.

The 2024 CMS Interoperability and Prior Authorization Final Rule requires Medicare Advantage and Medicaid managed care plans to make PA decisions within 7 days (standard) or 72 hours (expedited) by 2027, and to publish PA approval rates. State legislatures are also adding PA reform (timing limits, gold-carding programs that exempt frequently-approved physicians from PA).

When you'll hear it

Whenever a new specialty medication is prescribed, an MRI/CT is ordered, or surgery is planned. The single biggest source of friction in family caregiving today.

Is this the same as…?

Terms families frequently confuse with prior authorization.

Related terms

• Formulary — The list of prescription drugs an insurance plan covers, usually organized into tiers (Tier 1 generic = cheapest, higher tiers = brand-name + specialty = most expensive).
• Out-of-pocket maximum — The maximum amount you pay out of pocket in a plan year before insurance covers 100% of in-network care.
• Medicare Advantage — A private-insurance alternative to original Medicare (Parts A + B), bundling the coverage with extras like prescription drugs, vision, dental, gym memberships, and sometimes meal delivery.
• Medicare Part D — Prescription drug coverage.
• Medicaid — Joint federal-state program covering health care for low-income people, including many people with disabilities and many older adults who have spent down their assets.
• Durable medical equipment — Reusable medical equipment for long-term use at home: wheelchairs, walkers, hospital beds, oxygen concentrators, CPAP machines, glucose meters, lift chairs, etc.

See also: all glossary terms · conditions by name · step-by-step playbooks