What is a prior authorization?

Prior authorization is a medical insurance term that is used to describe a process of getting approval from an insurance company before a medical service is provided. The process is used in California to ensure that the healthcare service being provided is necessary and appropriate. Prior authorization by an insurance company generally involves the patient’s doctor submitting a request for coverage in advance to the insurance company for a healthcare service or medication. The provider must follow the plan’s guidelines for the authorization; this usually involves providing detailed information about the patient’s medical history, diagnosis, and the proposed treatment. The insurance company then reviews the request and makes a decision about whether or not to cover the service or medication. In California, once the provider receives authorization from the insurance company, the patient can go ahead and receive the service or medication. Without prior authorization, the patient may be responsible for the full cost of the service or medication. In addition, some plans may have limits on the number of times the service can be provided or the amount of medication that can be prescribed. Thus, it is important to obtain prior authorization before obtaining a medical service or medication.

Related FAQs

What is a premium?
What is a health insurance rider?
What is an out-of-pocket minimum?
What is an employer mandate?
What is a coinsurance cap?
What is a fee-for-service plan?
What is an insurance premium tax credit?
What are the different types of health insurance deductibles?
What is an administrative appeal?
What is a Health Savings Account (HSA)?

What is a prior authorization?

Related FAQs

Related Blog Posts