Prior authorization is your insurer’s advance approval for certain services, drugs, or procedures before it will pay. If required and not obtained, the claim can be denied — but a missing authorization is often fixable, and a denial of the authorization itself can be appealed.
Prior authorization is a cost-control step insurers use for specific medications, imaging, procedures, and equipment: your provider must get the insurer’s approval before the service, or the claim may be denied. It is a frequent source of surprise bills when the step is missed or the approval is denied as not meeting criteria. The good news is that both problems have paths forward — a missing authorization can sometimes be obtained retroactively, and a denied authorization can be appealed with clinical support, just like a claim denial.
Usually your provider requests it, but the financial consequence falls on you if it is missed. It is worth confirming it was obtained before a major service.
Yes. Like a claim denial, a denied prior authorization can be appealed with clinical documentation, and then taken to external review if needed.
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