Medical prior authorization: the other “prior auth”
In U.S. healthcare, prior authorization is a health plan's approval before it will cover certain care. It has nothing to do with a payment-card hold — this page exists because the same two words cause constant confusion.
What it means
Medical prior authorization (also called pre-certification or pre-approval) is a health plan's decision that a prescription, test, procedure, treatment, or hospital service is covered under the plan — often made before the care happens. If the plan requires authorization and none is obtained, the plan may refuse to pay, leaving the patient with the bill. The card-hold kind of pre-authorization reserves money on a bank card; the medical kind approves coverage. Different industries, different rules, same shorthand.
How to check whether you need it
- Ask your doctor, specialist, pharmacy, or hospital team — provider offices deal with these requirements daily and usually know which services need approval under your plan.
- Check your plan documents or your insurer's member portal for the list of services requiring authorization.
- Call the health plan using the member-services number on your insurance card.
- Confirm who is submitting the request — the provider usually does — and what records are needed to support it.
- Ask for the authorization number, the status, and any limits or expiration date, and keep them with your records.
If a prior authorization is denied
Ask for the reason in writing, the deadline to respond, and the insurer's appeal or grievance process. Your care team may be able to supply missing clinical information, request a peer-to-peer review, or discuss alternatives the plan will cover. Denials are frequently documentation problems rather than final answers, so treat the first “no” as the start of a process, not the end of one.
Looking for the card kind instead? Start with the U.S. card hold guide.