Prior Authorization
A health-insurance process that requires your doctor to get advance approval from your plan before it will cover a specific medical service, procedure, or prescription drug. It is meant to verify that the treatment is medically necessary and meets the insurer's coverage guidelines.
Source
Definition adapted from the National Association of Insurance Commissioners (NAIC), "What is Prior Authorization?" — the standards body for state insurance regulators.
Related NAIC consumer guide: "What Is Medical Necessity?" (PDF) — hosted by NAIC.
Key Points (per NAIC)
- Emergency care is exempt — it never requires prior authorization.
- Original Medicare (Parts A & B) generally does not require it; Medicare Advantage and Part D plans may.
- A plan may deny on cost grounds — approving a drug only if you first try a cheaper one that fails or causes side effects (the overlap with step therapy).
- A denied decision can be appealed, usually with your provider's help.
On AbilityForge
Prior authorization is the mechanism much of the Problem and Remedy rooms are built around — the point where an insurer decides whether care a physician has already prescribed will actually be paid for. When that decision delays or denies medically necessary treatment, it becomes the wrongful-denial pattern this site documents.