Prior authorization
Prior authorization is a payer’s requirement that a provider obtain approval before delivering certain services — without it, the payer may not cover the care.
Updated
Prior authorization (also called pre-authorization or precertification) is a payer’s advance approval that a specific service, medication, or procedure is covered before it is provided. For services that require it, delivering the care without the approval risks a denial.
Which services require prior authorization varies by payer and plan and changes frequently.
In practice
A service that needed prior authorization but was delivered without it is a common and often difficult-to-overturn denial. Tracking each payer’s authorization requirements is a front-end discipline that prevents avoidable back-end losses.
Commonly confused with
- Referral: A referral is one provider directing a patient to another (often a primary-care physician to a specialist); prior authorization is a payer’s approval of a service.
- Predetermination: A predetermination is a non-binding estimate of coverage; prior authorization is a required (mandatory) approval to obtain — though obtaining it is not itself a guarantee of payment.