The insurance gatekeeping step that delays care — explained.
Prior authorization is a process where your health insurance company decides if they will pay for a specific treatment or medication. You must get their approval before you receive the care. If you skip this step, the insurance company will likely refuse to cover the cost, leaving you responsible for the entire bill.
Insurance companies use this process to control their spending and monitor healthcare usage. They want to ensure that a prescribed test or drug is considered medically necessary for your specific condition. Essentially, they are checking if there is a cheaper alternative they prefer to cover instead.
When your doctor orders a scan or drug, their office sends a request to the insurance company with your medical records. The insurer reviews the documents and sends back an approval, a denial, or a request for more information. This back-and-forth often causes frustrating delays in starting your treatment.
A denial is not always the end of the road. Your doctor can file an appeal, which is a formal request for the insurer to reconsider their decision based on additional evidence. We provide more detailed clinical data to show why the specific treatment is the right choice for your health.
Keep your own records of every communication you have with your insurer. If you are waiting on a decision, ask your doctor’s office if they have submitted all required forms. Being proactive helps avoid preventable mistakes that could keep you from getting the care you need.