How Does Precertification (Prior Authorization) Work?

Precertification—sometimes called prior authorization—is a review your plan does before certain non-emergency procedures to confirm they're medically necessary and covered. Your provider submits the request, the plan reviews it, and an approval or denial goes to both the provider and you. Emergencies do not require precertification.

What gets reviewed, and what doesn't

Non-emergency procedures generally require precertification. Emergencies do not—emergency care is covered without prior approval and is instead reviewed retrospectively (after the fact, typically within 48 hours). So if you have a genuine emergency, you should never delay care waiting on a precertification.

For planned, non-emergent procedures, precertification is the step that confirms coverage before the service happens.

How the process works

1. Your provider submits the precertification request—these come directly from providers, not patients.
2. The plan reviews the request for medical necessity and plan coverage.
3. An approval or denial is sent to both the provider and the member.
4. If needed, a peer-to-peer conversation between physicians may be scheduled to resolve a decision.

Precertification is independent of where you receive care. Because there are no network limitations on where care can be provided, the plan will work with any facility to arrange financial clearance at plan-approved rates.

If a precertification is denied

A denial can be appealed, and appeals are reviewed the same way the original request was—for medical necessity and coverage. If your provider had been submitting to a previous network or administrator, they may simply need to resubmit to the current plan administrator. Your provider can handle the resubmission and appeal on your behalf.

The bottom line

Precertification is a pre-approval step for non-emergency procedures, handled by your provider and reviewed for medical necessity. Emergencies are always covered without it. If a request is denied, it can be appealed and resubmitted. Check your plan documents or call the precertification line listed in your enrollment materials for procedure-specific requirements.

This article explains how precertification generally works and is not a description of any specific plan's benefits. For your plan's requirements, see your plan documents or contact the plan administrator.