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.
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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 2026-06-14
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