My claim was denied
Do I need my plan's OK before this test or surgery?
Photo: Kaboompics / Pexels
Sometimes, yes. Prior authorization is your plan's approval, given before certain care, that the care is medically necessary. It is not a promise to pay, but without it the plan may not pay at all.
What to do
- Ask the doctor's office if the test, procedure or drug needs prior authorization, and who is sending the request.
- Call your plan to confirm the request arrived. Get the authorization number and the dates it covers.
- Check that the approved dates, place and service match your appointment. If one changes, a new request may be needed.
- If the request is denied, ask the plan for the reason in writing and what would change the answer.
What to say
I'd like to confirm that a prior authorization request was received for this service. Can you give me the authorization number and the dates it covers?
Call the number on the back of your insurance card, and write down the date, the name and the reference number.
What to watch out for
This is a sensitive stepSmall details here can change the outcome, and some mistakes are hard to undo. We highly recommend a free 15-minute call with us before you decide.
Assuming the doctor's office handled it. The office usually sends the request, but you are the one who gets the bill if it never went through.
Better done together
We’re here to help
Prior authorization can hold up care that you need now. We help you find out whether it's needed, who has to send what, and what to do if the answer is slow or no, and we show you how to follow it up yourself next time.
Every situation is different, and these are sensitive moments, so we look at yours with care. We often see what others miss, and we never take commissions from insurance companies: the only thing we are working for is what is right for you.
Free · 15 minutes · No pressure
The rule behind it
Which care needs prior authorization is set by your plan and spelled out in your plan documents, such as the Evidence of Coverage. An approval means the plan agrees the care is medically necessary; it is not a promise to pay, and the claim can still be denied for another reason. Since January 1, 2024, Medicare Advantage plans must follow Original Medicare's coverage rules and may use prior authorization only to confirm a diagnosis or medical necessity.
Sources
- HealthCare.gov — Glossary: Preauthorization
- CMS — 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) fact sheet
- CMS — FAQ memo on coverage criteria and utilization management (applicable from January 1, 2024)
- Medicare.gov — Understanding Your Medicare Advantage Plan's Provider Network
- Your plan's Evidence of Coverage and the approval letter
Amanda Alcodia
Education, not medical, legal or insurance advice.
Useful next steps
Start with the free Kit. If your situation needs a person, the intro call is free too.