Health Insurance

Prior Authorization

Prior authorization is an insurer's cost-control mechanism that can delay care if approval is not obtained in advance.

Last reviewed: May 2026 · Editorial methodology

Definition

Prior authorization (PA), sometimes called pre-certification or pre-approval, is an insurer's requirement that a physician obtain approval before delivering specific medical services, prescribing certain drugs, or ordering high-cost imaging. The insurer reviews the clinical documentation to verify that the requested service is medically necessary and appropriate under the patient's plan. Without PA, the insurer may deny the claim entirely, leaving the patient responsible for the full cost. Federal rules finalized in 2024 and taking effect through 2026 require most payers to respond to standard PA requests within seven calendar days and urgent requests within 72 hours. If a prior authorization is denied, members have the right to appeal and, in many states, to request an independent external review. Providers and patients should initiate the PA process well before the date of service and keep reference numbers for all approvals. Failure to obtain PA for a service that requires it is one of the most common causes of unexpected medical bills.

Where this term matters

Health Insurance →Medicare →

Tip

Glossary definitions are educational. Always check your own policy language — insurers can define common terms differently from one another. When in doubt, request a written explanation from your agent.

Related terms

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Related guides

Source: Cover Forge USA editorial team|Last verified: May 2026|Methodology
Definitions are educational and may be simplified. Always refer to your policy contract and consult a licensed agent for terms that affect coverage decisions.
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Cover Forge USA Editorial Team

Editorial Lead

This article was researched and written by the Cover Forge USA editorial team against federal sources (NAIC, CMS, FEMA, DOL, SSA, state DOIs) and standard policy forms. Bylines organize content by topic — they do not assert individual licensure. See our editorial-policy for details.

Reviewed June 2026

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