“Preauthorization” or “prior authorization” (they mean the same thing) is when your health plan must review your doctor’s treatment plan before covering it. *
Services that may require preauthorization include:
- Admission to a rehabilitation facility, skilled nursing facility, or hospital for non-emergency reasons.
- Elective procedures, like sleep studies or cosmetic procedures, such as eye lifts or varicose vein surgery.
- Certain medical equipment, such as motorized wheelchairs or devices to treat sleep apnea.
- Some outpatient or non-emergency radiology services, including CT scans, MRIs, or PET scans.
Not every service or drug needs preauthorization, and the lists may be different for different plans. Look at your plan documents (on your plan’s website[LD1] [HN2] ) for the list that applies to your plan.
Why health plans have preauthorization
Preauthorization may seem like a lot of red tape, but it’s done with your health in mind. Preauthorization can:
- Help to make sure you receive drugs that are cost-effective and appropriate for your condition.
- Confirm medical or surgical services are medically necessary, follow national standards of care, and are covered by your plan.
- Help find the most appropriate setting for your care. An example: Perhaps you can visit an ambulatory surgical center rather than a hospital for a test or procedure.
What do I need to do?
Always ask your doctor if a drug or treatment requires preauthorization. Your doctor will know (or know how to find out) what services and medicines need it. And, in most cases, your doctor’s office will contact the health plan to get preauthorization.
When in doubt, contact your health plan yourself. If you do not get preauthorization, then the medical service or drug may not be covered or may cost you more.*
*What you pay for a service or drug covered by your plan depends on your plan’s deductible, copayments, and/or coinsurance. Some drugs have limited quantities. Your doctor will need to request preauthorization again after you reach the limit.