Authorizations and Prior Authorizations

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One of the words you’re likely to come across with your health insurance plan is “authorization”. You might see it a lot, so it’s important to understand what it means. 

Let’s start with some background. As a member of a health insurance plan, your health insurer helps pay some of your medical bills (in return, you may pay them monthly premiums).

Your health plan will let you know which medical services they will help pay for, and which ones they won’t. Typically, things like getting your annual physical and emergency care are covered by your plan. On the other hand, things that aren’t needed to keep you healthy, such as cosmetic surgery, normally aren’t covered by health insurance.

Authorizations

Authorizations make the difference between a medical service being covered or not covered.

With some medical care, your health insurer will only pay for the service if you get an approval from them. That approval is called an “authorization”.

Sometimes, you’ll need to get an authorization for medical care that you’ve already received. For example, suppose you got emergency care that was out-of-network: your health plan might require you to get an authorization from them before they pay for it.

Prior Authorizations

More often, though, your health plan will require you to get approval before you receive certain medical care. This “pre-approval” can go by several names:

  • prior authorization
  • prior approval
  • preauthorization
  • precertification

Health insurance companies usually require you to get a prior authorization for physical therapy, certain surgeries, prescription drugs, tests or scans, medical equipment or other medical care.

(You might have seen something similar with your credit or debit cards, where you can’t make a large purchase or buy something outside the country without an authorization before or soon after making the purchase. Otherwise, the payment won’t go through.)

Authorizations are a way for health insurers to make sure members get care that is medically necessary (“medically necessary” is a term that pops up frequently in discussions about authorizations). If a medical service isn’t likely to make the member healthier, then health insurers aren’t likely to pay for it. They want to focus resources on care that is proven to make patients healthier.

Usually, if you need a prior authorization, your doctor’s office or pharmacy will work with your health insurer to get it. You won’t have to do anything or submit any paperwork or application.

Learn More

Again, your health insurer will let you know which medical services they cover, and which ones require an authorization. This information is included in your plan contract with your health insurer, sometimes called a “member handbook” or Evidence of Coverage.

If you’re a member of Virginia Premier, you can always contact Member Services if you have a question about authorizations.

And if you’d like to know more about how health insurance helps you with your medical costs (and to stay healthy), see What is Health Insurance and Why is it Important?

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