What is Prior Authorization?
Definition
Prior authorization is the insurer's approval requirement before a specific medication, procedure or hospital admission will be covered. The provider must submit clinical justification and receive a formal approval number, or the claim will be denied even for medically necessary care.
Real-World Example
A rheumatologist prescribes a $6,200-per-month biologic. The pharmacy cannot dispense it until the insurer's utilization management team reviews the chart and issues a PA number, typically within 3 to 15 business days.
Why It Matters
Prior authorization is the single largest source of provider denials in the U.S. and a top complaint at state insurance regulators. Knowing how to appeal — and the 72-hour expedited timeline — protects access to essential care.
Frequently Asked Questions
Can I appeal a prior authorization denial?
Yes. Federal law guarantees an internal appeal and, if that fails, an external independent review.