A doctor takes notes as a patient moves into the MRI machine.

Make the Most of Your Health Insurance: Getting Pre-Authorizations

Making sure that you have adequate health insurance that covers the care that you need is only step one. You also need to know how to use your insurance, so that you don’t pay more for your care than you need to.

A good example of this is understanding and getting pre-authorizations before you get any medical care.

What are Pre-Authorizations?

Health insurance companies may require you to get their written approval, before you get medical care, if you want them to pay for that care.

You may need to get pre-authorizations when you are getting certain types of medical care, using certain medical devices, or taking certain prescription drugs.

Are There Other Names for Pre-Authorization?

Yes! The process can also be called prior authorization, advanced/prior approval, precertification, or a treatment authorization request.

What Happens if You Don’t Get Pre-Authorization?

If your health plan requires you to get a pre-authorization before getting medical care, and you don’t get the pre-authorization, then it may not pay for that care.

How Do You Know if You Need a Pre-Authorization?

Unfortunately, most health insurance companies do not provide a list of medical services that require pre-authorization. Although, some do. So, it is important to ask your insurance company if the care that you need requires pre-authorization.

Ultimately, it is your responsibility, as the patient, to get pre-authorizations. But many health care providers will get pre-authorizations for you. You may not even know it is happening because your health care team takes care of it.

But it is important for you to know what your plan requires, because if your health care team doesn’t get the pre-authorization and it was required, you may be stuck paying the bill.

What Are Common Services That Require Pre-Authorization?

  • Medical treatments and medications that should only be used for certain health conditions
  • Lab tests, imaging scans, and biomarker tests

How Long Does It Take to Get a Pre-Authorization?

Many plans are required to decide on a pre-authorization request within 14 days; however, some states have laws requiring a faster response.

What Happens if Your Plan Denies a Pre-Authorization?

Studies show that some health insurance companies deny up to 9% of medical care based on lack of pre-authorization. A study in Texas showed health insurance companies may make 22% – 24% of their denials, based on not having a pre-authorization.

But there is some good news: you do not have to accept “no” from your insurance company.

Instead, you can appeal a denial of a pre-authorization, or coverage of care. While the appeals process can feel like an additional, overwhelming step, it is an important step to take.

The steps to appeal depend on the type of health insurance plan you have. If you have an individual or employer plan, you generally have access to an internal and external appeal.

An internal appeal is when you go back to your health insurance company and ask them to reconsider. An external appeal takes the decision out of the insurance company’s hands and is based on whether the care you need is medically necessary. Your health care team can help with this process.

Patients are more likely to get the care that they need, if they use the appeals process. On average, 50% of the time, patients actually win their external appeal and receive coverage!

How Can I Learn More?

To learn more about navigating pre-authorizations, see our Quick Guide to Pre-Authorizations for Individual & Employer-Sponsored Health Insurance.

Triage Cancer has many resources related to health insurance appeals. Check out our Quick Guide to Appeals for Employer-Sponsored & Individual Health Insurance.

For more detailed information on appeals, including Medicare and Medicaid, visit our Health Insurance Appeals Module.

About Triage Cancer

Triage Cancer is a national, nonprofit providing free education to people diagnosed with cancer, caregivers, and health care professionals on cancer-related legal and practical issues. Through eventsmaterials, and resources, Triage Cancer is dedicated to helping people move beyond diagnosis.

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