What Is a Prior Authorization?

Prior authorization—also known as preauthorization, precertification, or preapproval—is a review process that health insurance companies use to determine whether a specific treatment, medication, or procedure is medically necessary and covered under a patient’s plan.

This review takes place before the service is provided and often serves as a checkpoint to help ensure patients receive appropriate care. Without prior authorization, a patient may be responsible for the full cost of care, even if it would otherwise be covered by insurance.

What Is The No Surprises Act?

The No Surprises Act, a landmark federal law that took effect on January 1, 2022, is designed to protect patients from unexpected—and often expensive—medical bills resulting from out-of-network care. It also strengthens price transparency, aiming to eliminate what’s commonly known as “surprise billing.”

Surprise bills typically occur when patients unknowingly or unexpectedly receive care from out-of-network providers, even though they sought treatment at in-network facilities. The most common scenarios involve emergency care or ancillary services during scheduled procedures—such as those provided by anesthesiologists, pathologists, or radiologists—that may not be in the patient’s insurance network.

READ MORE: What is the No Surprises Act?

Why Do Insurers Require Prior Authorization?

Ensure Medical Necessity

Prior authorization helps insurance providers confirm that a recommended service is consistent with clinical guidelines and supported by medical evidence. This helps reduce the risk of unnecessary or ineffective treatment and encourages providers to pursue care that is proven to be beneficial for the patient’s specific condition.

Manage Rising Costs

Prior authorization also plays a role in cost containment. By reviewing high-cost treatments in advance, insurers can recommend equally effective but lower-cost alternatives, such as a generic drug in place of a brand-name option. This helps reduce unnecessary spending across the healthcare system while still allowing patients to receive the care they need.

Promote Patient Safety

This process provides an added layer of clinical review that can help identify potential safety concerns, such as duplicate therapies, drug interactions, or redundant testing. For patients, this can mean fewer adverse effects and a greater focus on care that delivers the most benefit with the least risk.

READ MORE: Prior Authorizations vs. Benefits Investigation

How to Get a Prior Authorization

1. Provider Submits a Request

The process begins when a healthcare provider submits a prior authorization request to the patient’s insurance company. Prior authorization processing typically includes medical records, clinical notes, and a formal explanation of why the service is necessary.

2. Insurer Reviews the Submission

A clinical team at the insurance company—often made up of nurses, pharmacists, or physicians—reviews the request. They assess the treatment against the patient’s health plan and established medical guidelines to determine whether it qualifies for approval.

3. Additional Information May Be Requested

If the initial submission is missing key documentation or raises clinical questions, the insurer may reach out to the provider for more information. This can delay the decision process by several days or longer, depending on how quickly the requested information is returned.

4. Decision Is Issued

Once the review is complete, the insurance company issues a decision. For routine, non-urgent requests, a determination is typically made within one to three business days. For urgent requests, insurers are expected to respond more quickly —often within 24 to 72 hours.

5. Appeal If Denied

If a request is denied, patients and providers have the right to appeal. Appeals may involve submitting additional clinical documentation or requesting a peer-to-peer review.

How Long Does Prior Authorization Take?

The length of the prior authorization process can vary based on the type of request and the complexity of the case.

• Standard Requests: Typically reviewed within 1 to 3 business days.
• Urgent or Expedited Requests: May be reviewed in as little as 24 to 72 hours.
• Complex Cases or Appeals: May take several weeks, particularly when additional documentation or multiple levels of review are required.

Emergency situations do not require prior authorization, but cost coverage will depend on your health plan.

READ MORE: How Long Does Prior Authorization Take?

When Prior Authorization Is Commonly Required

Certain types of care are more likely to require prior authorization, including:

• Specialty medications or high-cost prescriptions such as biologics.
• Advanced diagnostic imaging, including MRI, CT, and PET scans.
• Inpatient or outpatient surgical procedures, especially those that are elective.
• Treatments with less expensive, proven alternatives, such as therapy instead of surgery.

Ongoing Challenges With Prior Authorization

Delays in Care

One of the most frequently cited concerns about prior authorization is the impact it can have on timely access to care. Providers report that patients often face significant delays, and in some cases, may abandon treatment entirely. Studies have shown that nearly one in three physicians link prior authorization delays to serious adverse events.

READ MORE: careviso Survey Highlights Patient Frustration with Healthcare Cost Transparency and Prior Authorization Delays

Administrative Strain

Managing prior authorization requests is time-consuming. Many practices have to allocate full-time staff to handle the paperwork and communication required by insurers. This in turn increases operating costs for healthcare practitioners.

Inconsistent Requirements

Each insurance plan may have different criteria for what requires prior authorization and what documentation is necessary. These inconsistencies can create confusion for providers and increase the likelihood of delayed or denied care due to technical errors or omissions.

How Can Prior Authorization Improve?

Digital Tools

Many stakeholders are moving toward electronic prior authorization (ePA) systems like seeQer prior authorization software. These tools allow providers to submit requests directly from their electronic health records (EHRs) and often receive faster decisions for routine cases.

Regulatory Reform

Legislation aimed at streamlining the prior authorization process continues to gain momentum. Federal rules set to take effect in 2026 are designed to enforce decision timelines, reduce administrative burden, and improve transparency for both patients and providers. Other bills such as the Improving Seniors’ Timely Access to Care Act will further support this reform.

How careviso Helps

careviso’s platform, seeQer, was built to simplify and streamline the complexities of prior authorization. By integrating directly into provider workflows, seeQer delivers real-time visibility into a patient’s eligibility, insurance requirements, and out-of-pocket costs before services are rendered. This enables providers to make faster, more informed decisions while reducing delays in care.

Prior authorization plays a critical role in today’s healthcare system, ensuring that treatments are both clinically appropriate and covered under the patient’s plan. But as the process grows more complex, it also presents real barriers to timely care, especially for patients with serious or chronic conditions.

With advanced tools like careviso’s seeQer platform, the path forward is becoming clearer. By combining automation, financial transparency, and deep payer expertise, careviso is helping providers reduce administrative burden, lower costs, and deliver care without unnecessary delays.

READ MORE: careviso Achieves 2 Million Prior Authorizations