How Prior Authorization Works

Prior authorization (PA) — also called pre-authorization, pre-certification, or pre-approval — is a requirement by health insurers that physicians obtain approval before prescribing certain medications, ordering specific tests, or performing certain procedures. Designed originally to prevent unnecessary use of expensive treatments, prior authorization has become one of the most widespread sources of friction, delay, and administrative burden in U.S. healthcare — affecting patient care, physician time, and healthcare outcomes in significant and often harmful ways.

What Prior Authorization Is

Before paying for a covered service that requires PA, the insurer requires the prescribing physician to submit documentation demonstrating that the service is medically necessary according to the insurer's criteria. The insurer (or its contracted PBM or utilization management company) reviews the request and either approves, denies, or requests more information.

PA applies to:

• Many prescription medications (particularly brand-name drugs, specialty drugs, and drugs used outside standard indications)
• Advanced imaging (MRI, CT scan, PET scan) in many plans
• Specialty procedures (certain surgeries, complex cardiac procedures)
• Durable medical equipment (CPAP machines, wheelchairs, insulin pumps)
• Rehabilitation services (physical therapy beyond initial episodes)
• Certain diagnostic tests