What is a prior authorization?

Prior authorization is a requirement in certain health insurance plans that a patient must get approval from their insurance company before they can receive certain medications or medical services. In Washington, prior authorization is required for many common medical services and treatments, including dental procedures and physical therapy. Prior authorization is put in place to help the insurance company make sure that they are only paying for medically necessary services. By evaluating the patient’s condition and potential treatments, the insurer can decide which services should be covered and which they should not. Prior authorization is also used to ensure that the patient is getting the most cost-effective treatment. For example, if the insurer finds that a certain procedure will cost more than an alternative treatment, they may not cover the more expensive procedure. In Washington, a prior authorization usually must be obtained for services that will cost over $500, as well as certain medications. The patient should contact their insurance company before the medical appointment or treatment to see if they will need to get a prior authorization. The insurer will then review the request and decide if the procedure or treatment is medically necessary and if it will be covered.

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