Prior Authorization

What it means

A requirement by an insurance plan that a doctor get permission before providing certain services. The doctor submits paperwork explaining why the service is needed. The insurance company reviews it and says yes or no. If denied, the doctor can appeal. If the patient gets the service without prior authorization, insurance may refuse to pay. Medicaid and most managed care plans in New York use prior authorization for some prescriptions, imaging (like MRIs), surgeries, and specialist visits. Emergency care never requires prior authorization.

When you might hear this

You hear this when a doctor wants to order a test, procedure, medication, or specialist visit and the insurance company says it needs to approve it first. It can delay care by days or weeks.

What to ask