Prior authorization is the insurer’s requirement that a service be approved before it happens. Imaging, surgery, specialty drugs and some procedures routinely need it. Without approval, the plan can refuse to pay even for care that was clinically appropriate.
Who does the work: the prescribing office submits it. What patients control is timing and follow-up — and follow-up is usually what moves it.
When it’s denied, the denial is not the end of the process:
- Ask for the denial in writing, with the specific reason and the clinical criteria applied.
- Ask the prescriber for a peer-to-peer review — a direct call between your doctor and the plan’s reviewer. This resolves a meaningful share of denials.
- File an internal appeal with the plan.
- If that fails, New York provides an external appeal to an independent reviewer, with its own deadlines.
Emergency care does not require prior authorization. If a plan denies an emergency claim on those grounds, that denial is worth appealing rather than paying.
Keep a dated log of every call: who, when, what was said. Appeals turn on documentation, and the plan has better records than you do unless you keep them.
Also called: pre-authorization, precert, prior auth. Reference: Prior authorization on Wikipedia — general definition, not New York specifics.
More in Glossary of health coverage and billing terms
- Sliding scale fee — A charge set by your income rather than a fixed price list. The standard at community health centers.
- Good faith estimate — A written cost estimate uninsured and self-pay patients are entitled to before scheduled care.
- Balance billing — When a provider bills you for the gap between its charge and what your plan paid.
This page explains how the system works. It is not medical advice. More.