Prior authorization

What does Prior authorization mean on a medical bill?

Prior authorization is your plan's approval, obtained before certain care happens, that the service meets its coverage rules. The provider's office normally requests it, and emergency care is generally outside the requirement. An approval is not a promise of payment — the claim still has to match what was approved. When the step gets skipped, the claim comes back denied for authorization, which is an office problem that landed on your statement, so the first call goes to whoever was supposed to request it.

What should I watch out for with Prior authorization?

• A denial for missing authorization on care the provider arranged — ask them to appeal, since they filed the request
• Ask for the authorization number and the dates it covers before a scheduled procedure
• A procedure that grew beyond what was approved — ask the provider to refile with the operative records