Definition
Prior Authorization
Advance approval from your insurer required before receiving certain services.
Prior authorization (also called pre-authorization or pre-approval) is a requirement by some health plans that you obtain approval before receiving certain procedures, medications, or specialist visits. If prior authorization was required and not obtained, your claim may be denied. However, under ERISA and ACA regulations, insurers must provide a specific, documented reason for a prior authorization denial — and that denial is subject to the same full and fair review appeal rights as any other coverage denial. Inadequate notice of prior authorization requirements can itself be grounds for appeal.
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