What is Prior Authorization?

Prior authorization (PA), sometimes called preauthorization, is a requirement to obtain approval from a patient’s insurance company before certain tests, treatments, or procedures are performed.

If prior authorization is not obtained before services are rendered, the insurance company may refuse to cover the test, even if it is medically necessary, leaving the patient responsible for paying the full cost.

How Do I Know if Something Requires Prior Authorization?

Health insurance plan details should include a description of covered benefits and terms of coverage. Insurers are increasingly requiring prior authorization for molecular genetic tests, which are tests that examine DNA or RNA.

How Can I Obtain Prior Authorization?

Each health insurance company has a unique process for submitting prior authorization requests.

Typically, most insurers require the following information:
• CPT Code: Identifies the type of test, treatment, or procedure
• ICD-10 Code: Identifies a symptom or diagnosis

The ordering physician, their staff, or the healthcare facility will submit this information for review by the insurance provider. This process can take several weeks to complete.

What Determines Authorization?

The insurer will review the CPT and ICD-10 codes to see if the request complies with their coverage policies and if it meets their “medical necessity” requirements.

In some cases, the insurer will request additional information about why the test is being ordered and how the results could change the preventive care, treatment, or management of the patient.

If Something Receives Prior Authorization, Does That Mean That the Patient Will Not Have to Pay?

Prior authorization is not a guarantee of payment by the health insurance company.

A patient’s out-of-pocket expense may be impacted by their specific plan, including yearly deductibles and co-pays.  Patients should contact their insurance provider for specific information regarding their coverage.