Prior authorization
Confirm before the service whether a payer requires advance approval, obtain it, and make sure the claim matches what was authorized — the front-end control that prevents an often-unappealable category of denial.
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What is prior authorization?
Prior authorization is a payer's requirement that certain services be approved in advance, against the plan's coverage and medical-necessity criteria, before they are delivered. For a service that requires it, providing the care without the approval risks a denial that is often difficult to overturn after the fact.
This section covers the work that decides whether a service can be billed at all: telling prior authorization apart from a referral and from the overlapping terms payers use for it, determining which services require it, gathering the clinical documentation that supports the request, submitting and tracking it, and then making sure the claim that follows matches the units, dates, and services that were approved.
Which services require authorization varies by payer, plan, and time, and so does every timeframe in the process. The articles here teach the durable structure — the decisions, the documentation, and the failure modes — rather than any figure that a payer sets and changes. A service that needed authorization but was delivered without it is a preventable loss, which is why this work sits at the front of the revenue cycle alongside eligibility.
Where to start
A path from what prior authorization is to a request that will support a payable claim. Each article assumes the one before it; the full set continues below.
Understand what prior authorization is
The advance approval a payer requires for certain services, why delivering the service without it risks an often-unappealable denial, and where it sits in the revenue cycle.
Read: What is prior authorization?Tell it apart from a referral
A referral and an authorization are different requirements from different parties, and a service can need one, both, or neither — confusing them is a common, avoidable denial.
Read: Prior authorization vs. referralSort out the overlapping terms
Precertification, predetermination, and prior authorization are used differently by different payers — which one governs a claim is the one in that payer's policy.
Read: Precertification, predetermination, and prior authorizationFind out what requires it
How to determine whether a specific service needs authorization for a specific plan, and why the answer is a per-payer, point-in-time fact rather than a fixed list.
Read: Which services require prior authorizationSee the end-to-end workflow
The full sequence from identifying the requirement to submitting the request, tracking the decision, and reconciling the approval with the claim.
Read: The prior authorization workflowGather the documentation
The clinical evidence a request has to carry to establish medical necessity — assembled from the record, never invented to fit a criterion.
Read: Gathering clinical documentation for authorization
Featured articles
Start here if you are new to prior authorization.
What is prior authorization?
Prior authorization is a health plan's advance review that decides whether a proposed service, drug, or item is covered before it is delivered, based on the plan's coverage and medical-necessity rules.
Updated · 8 min readThe prior authorization workflow
The prior authorization workflow is the end-to-end process of confirming an approval requirement, building and submitting a request, tracking it to a decision, and reconciling the outcome against the billed claim.
Updated · 7 min readAll articles
20 articles in this section.
Foundations4
The authorization workflow6
Billing against the authorization2
Program- and service-specific rules5
Related services
The service that runs front-end work like this for a practice.
Related topics
Where prior authorization sits in the wider revenue cycle.
Eligibility verification
The front-end coverage check run together with authorization; the benefit response is often where an authorization requirement first surfaces.
Denials & Appeals
The category of denial an authorization exists to prevent — and what to do when an authorization-related denial still lands.
Claims
What happens once the service is authorized and a claim is built — where the approval and the claim have to agree.
Related resources
Operational support for front-end authorization work.
Key terms to understand
Plain-language definitions, defined once on their glossary pages.
About this section
What does the Prior Authorization section cover?
The front-end work of getting a payer's advance approval for services that require it: distinguishing authorization from a referral and from the overlapping terms payers use, determining which services need it, gathering the supporting documentation, submitting and tracking the request, handling approvals, denials, and peer-to-peer reviews, and reconciling the approval with the claim. It also covers the setting-specific variations — medications, Medicare Advantage, and Medicaid — and the federal rule aimed at streamlining the process.
Is prior authorization the same as confirming a patient is eligible?
No, though the two are run together at the front end. Eligibility verification confirms that coverage is active and, with benefit detail, what the plan covers. Prior authorization is a separate, service-specific approval a payer must grant before certain services. An eligibility or benefit response often reveals that a service requires authorization, but obtaining that approval is a distinct step — and having it is not, by itself, a guarantee of payment.
Why doesn't this section list which services need authorization or how long it takes?
Because there is no honest universal answer. Which services require prior authorization, what documentation is needed, and every timeframe in the process are set by each payer and plan and change over time. A list or a turnaround figure printed here would be out of date the moment a payer revised its policy. What is durable is the structure — how to find the current requirement, what a request has to establish, and how the approval and the claim have to line up — and that is what these articles teach.
Authoritative sources
- Centers for Medicare & Medicaid Services (CMS) (opens in a new tab)
Administers Medicare and Medicaid, sets Medicare prior-authorization programs, and issued the Interoperability and Prior Authorization rule.
- U.S. Department of Health & Human Services (HHS) (opens in a new tab)
Publishes guidance on coverage, utilization management, and patient protections.
- Healthcare Financial Management Association (HFMA) (opens in a new tab)
Publishes operational guidance on revenue-cycle practices, including authorization management.
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