You've scheduled an MRI for that persistent back pain, and then you get the call: your insurance company needs to approve it first. Welcome to the world of prior authorization, one of the most frustrating parts of using health insurance. But here's what most people don't know: prior authorizations exist for a reason, they're approved most of the time, and when they're not, you have real options to fight back. Let's break down what prior authorization actually is, when you'll need it, and how to navigate the process without losing your mind.
What Is Prior Authorization?
Prior authorization—also called preauthorization, prior approval, or precertification—is your health insurance company's way of making sure a treatment, test, or medication is medically necessary before they agree to pay for it. Think of it as a pre-approval process. Instead of just going ahead with an expensive procedure and hoping your insurance covers it, your doctor submits information to the insurance company first, explaining why you need this particular treatment.
The insurance company reviews the request and decides whether to approve it, usually within a few days. If approved, you're good to go. If denied, you have the right to appeal. The whole process typically happens behind the scenes between your doctor's office and your insurance company, though you'll want to stay involved to make sure nothing falls through the cracks.
When You'll Need Prior Authorization
Not every medical service requires prior authorization. Generally, you won't need it for routine office visits, preventive care, or emergency services. But for more expensive, specialized treatments, your insurance company wants to review the request first. Common services that typically require prior authorization include MRI, CT, and PET scans, surgeries and invasive procedures, hospital admissions and skilled nursing facility stays, certain expensive prescription medications, medical equipment like wheelchairs or CPAP machines, and specialty treatments where lower-cost alternatives exist.
Here's the practical reality: insurance companies use prior authorization for treatments where they want to make sure there's a good medical reason before approving what could be a five-figure bill. If your doctor prescribes physical therapy, you probably won't need prior authorization. If your doctor recommends spinal surgery, you almost certainly will. Your health plan maintains a list of services requiring prior authorization, which you can find in your plan documents or on your insurer's website.
One important exception: prior authorization is never required for emergency medical situations. If you're in an ambulance heading to the ER, nobody's calling your insurance company for approval first.
How the Prior Authorization Process Works
In most cases, your doctor's office handles the prior authorization paperwork. When your doctor recommends a treatment that requires prior authorization, someone from their office—usually a medical assistant or billing specialist—submits a request to your insurance company. This request includes your medical records, a letter explaining why the treatment is medically necessary, and any supporting documentation like test results or clinical notes.
The insurance company then reviews the request. Starting in 2025, new federal rules require insurers to respond within 7 calendar days for standard requests and 72 hours for urgent requests. Many states have enacted even faster timelines. The insurance company's medical reviewers look at whether the treatment is medically necessary, whether it follows accepted medical guidelines, and whether a less expensive but equally effective treatment might work instead.
Here's what surprises most people: the vast majority of prior authorization requests are approved. Data from 2024 shows that about 93% of requests get approved on the first try. That doesn't mean the process isn't frustrating—doctors and their staff spend an average of 13 hours per week completing prior authorization requests, processing about 39 requests per physician. But if you're worried your needed treatment won't be covered, the numbers are actually in your favor.
Your role in this process is to stay informed. Before scheduling an expensive procedure, confirm with your doctor's office that they'll handle the prior authorization. Ask for a timeline and follow up if you haven't heard anything. If you're prescribed a new medication and the pharmacy says it needs prior authorization, contact your doctor's office right away rather than waiting.
What to Do When Prior Authorization Is Denied
If your prior authorization request is denied, don't panic. This is where the system actually works in your favor if you know how to use it. Appeals succeed about 82% of the time, according to Medicare Advantage data from 2019 through 2023. The key is to act quickly and methodically.
First, contact your doctor's office immediately. They may already be working on an appeal, or they might not even know about the denial yet. Your doctor's office has dealt with this before and knows what documentation the insurance company typically wants to see. Second, file a formal internal appeal with your insurance company. You typically have 180 days to do this, though some plans only give you 60 days, so check your denial letter carefully for deadlines. Your appeal should include a written explanation of why the treatment is medically necessary, supporting medical records and test results, a letter of medical necessity from your doctor, and any relevant medical literature or clinical guidelines.
One powerful tool many people don't know about is the peer-to-peer review. You or your doctor can request that your doctor speak directly with a medical professional at the insurance company to discuss your case. These conversations often resolve denials because your doctor can explain nuances of your situation that didn't come through in the paperwork.
If your internal appeal is denied, you have the right to request an external review by an independent third party. At this point, the insurance company no longer has the final say. An independent medical expert reviews your case and makes a binding decision. Keep detailed records throughout this process—save every email, document every phone call with dates and names, and keep copies of all paperwork.
Recent Changes Making Prior Authorization Easier
The prior authorization landscape is improving. New federal rules taking effect in 2025 and 2026 are designed to speed up the process and reduce administrative burden. Insurance companies must now respond to standard prior authorization requests within 7 calendar days, down from longer timeframes. By 2027, insurers must develop electronic systems that allow doctors to submit prior authorization requests digitally, streamlining the whole process.
Many states are going even further. Wyoming created a gold card program that exempts doctors from prior authorization requirements if they have a strong track record of approvals. Minnesota eliminated prior authorization requirements for certain cancer treatments and mental health care. For chronic conditions in some states, once you get prior authorization approval, it doesn't expire as long as your treatment doesn't change, meaning you won't need to reauthorize every six months.
These changes are expected to save the healthcare system approximately $15 billion over ten years by reducing paperwork and administrative hassle. More importantly for you, they mean faster decisions and less waiting around to get the care you need.
Taking Control of Your Prior Authorization
The best way to handle prior authorization is to be proactive. Before any major procedure or expensive treatment, ask your doctor's office directly: Does this require prior authorization? Who will handle submitting the request? What's the typical timeline? Having these conversations upfront prevents surprises and delays.
Review your health insurance plan documents to understand which services typically require prior authorization. Many insurers now provide this information in easy-to-search online databases. If you're starting a new medication and your pharmacy says it needs prior authorization, don't wait—call your doctor's office that same day to get the process moving.
If you face a denial, remember that you have powerful appeal rights and the statistics are on your side. Work closely with your doctor's office, meet all deadlines, and don't be afraid to request a peer-to-peer review or escalate to an external review if needed. Prior authorization might be one of the most frustrating parts of health insurance, but it doesn't have to derail your care if you understand how to navigate the system.
