Getting Medical Pre-approval or Prior Authorization

Health insurance plans use a process called pre-authorization to make sure that a procedure or medicine is medically necessary.  Pre-authorization must be given before certain procedures are done or a prescription is filled. This is also called pre-approval or prior authorization.

Pre-approval for procedures

The pre-authorization (pre-approval) process is started by the treating health care provider. If a procedure is done or a prescription filled before it is approved, you could be charged for the full cost, with the insurer paying nothing.

Pre-authorization is most often required for more expensive treatments. Ask your health care provider if pre-authorization will be needed when planning for a new treatment or change in your care. They will probably tell you to talk to your insurance company or the facility billing department.

Pre-approval for prescriptions

Pre-authorization is often needed for expensive medicines. Sometimes insurance plans will want you to try a different medicine before they will approve the one your doctor prescribes. They may also limit how much of the medicine you can have at a time, or how many refills you can have. If your health care provider thinks that the insurance plan’s preferred medicine wouldn’t work or wouldn’t be safe for you, you can appeal the decision. See If Your Health Insurance Claim Is Denied.

Pre-approval for emergency care

The Affordable Care Act states that pre-authorization cannot be required for emergency care.  This is true whether the care is provided by an in-network or out-of-network health care provider or hospital. And if you need to get emergency care in an out-of-network hospital, your insurance plan can't make you pay more than you would in a network hospital.

 But be sure to find out what your insurance plan considers emergency care.  Many insurance plans provide resources to help you figure out what’s an emergency that needs to be treated in an emergency department.

For out-of-network care

You might also need to get pre-authorization before you go outside your network for care. Under most plans, members must use the services of certain providers or health care facilities that have contracts with the plan.

When you choose to go outside the network for care, you will likely have to pay more. You might also need to pay the full cost. Some plans will pay at least part of the cost if you get approval from the plan before the visit or service (also called pre-authorization). You may be more likely to get out-of network services covered if your plan does not offer a medically necessary service.

What if I didn’t know I needed pre-approval?

In situations where you didn’t know (and may not have had any way to know) you can appeal the insurance company’s decision to not cover the care or service. See If Your Health Insurance Claim Is Denied.

If you are unable to get your insurance company to pay, you can also try contacting the regulatory bodies that are in charge of the insurance company. If appeals and regulators do not help, you can try working with the health care provider or facility to get your bill lowered. See If You Have Problems Paying a Medical Bill.

When a treatment your doctor says you need isn’t approved

Ask your cancer care team to help you try and get the treatment approved. The insurance plan may need more information to support the use of the treatment. You can also ask your cancer care team if there is another treatment that might work as well, one which your plan is more likely to approve.

Check with the insurance company about how you can appeal these decisions just as you would a claim denial. You might be able to get them to reverse their previous decision.

Need more information?

US Department of Health & Human Services
Website:   www.healthcare.gov

For the most up-to-date information on health care and insurance laws and how they might affect you.

Cancer Legal Resource Center (CLRC)
Toll-free number: 1-866-843-2572 (may need to leave a number for a call back)
Website:  www.cancerlegalresources.org

Provides free legal information about laws and resources for many cancer-related issues including health insurance issues, denial of benefits, and government benefits.

National Association of Insurance Commissioners
Toll-free Number: 1-866-470-6242
Website: content.naic.org

Offers contact information for your state insurance commission. You can contact your state insurance commission for insurance information specific to your state, or report problems with your insurance company.

Patient Advocate Foundation (PAF)
Toll-free number: 1- 800-532-5274
Website: www.patientadvocate.org

Works with the patient and insurer, employer and/or creditors to resolve insurance, job retention and/or debt problems related to their diagnosis, with help from case managers, doctors, and attorneys. For cancer patients in treatment or less than 2 years out of treatment.

Medicare Rights Center (for those with Medicare)
Toll-free number: 1-800-333-4114
Website: www.medicarerights.org      

This service can help you understand your rights and benefits, work through the Medicare system, and get quality care. They can also help you apply for programs that help reduce your costs for prescription drugs and medical care, and guide you through the appeals process if your Medicare prescription drug plan denies coverage for drugs you need.

Triage Cancer
Phone number: 424-258-4628
Website: www.triagecancer.org

Provides free education and resources related to health insurance, medical bills, employment and disability.  

*Inclusion on these lists does not imply endorsement by the American Cancer Society.