Prior authorization is a plan rule that requires approval before certain services, procedures, equipment or medications are covered under the plan’s terms. It is not the same thing as a guarantee that every later claim will be paid.
Who usually submits the request?
For medical services, the treating office or facility often sends the request with clinical information. For prescriptions, the prescriber or pharmacy may trigger the process and the prescriber may need to send supporting information.
What you can do as a member
- Ask whether the service or drug needs authorization before it is scheduled.
- Confirm which office is submitting the request.
- Write down the reference number and submission date if one is available.
- Ask what additional information is needed if the request is incomplete.
- Keep copies of notices and follow the appeal instructions if coverage is denied.
Why requests can be delayed
Common practical problems include missing clinical notes, an incorrect billing code, a request sent to the wrong administrator, or a service scheduled before the review is complete. Clear communication between the member, provider and plan helps identify where the request is stuck.
When time matters
If care is urgent, ask the provider and plan whether an expedited review process applies. The exact standard and timing depend on the plan and the circumstances.