Skip to main content

Aptiva Health Schedule an appointment

How Prior Authorization Works (From the Patient’s Side)

Aptiva Health Editorial Team

2 min readLast reviewed June 15, 2026

Prior authorization is your insurer's approval before they will cover certain care. Understanding the process helps you avoid delays and unexpected bills.

Written by Aptiva Health Editorial TeamReviewed by Eric Lowe, Healthcare ConsultantEditorial & review standardsHow we research

What is prior authorization?

Prior authorizationYour insurer's approval before it will cover certain care, tests, or medicines. Without it, the claimA request your provider sends to your insurer to be paid for the care you received. can be denied. (also called pre-authorization or pre-certification) is when your insurance company must approve a service, medication, or procedure before they will agree to pay for it. Insurers use it for certain scans (like MRIMagnetic Resonance Imaging — an imaging test that uses strong magnets and radio waves (no X-ray radiation) to make detailed pictures of soft tissues such as muscles, ligaments, and spinal discs.), surgeries, some medications, and other treatments.

Why it exists — and why it can be frustrating

Insurers say it is meant to confirm care is “medically necessary.” For patients, it can cause delays and confusion. Knowing the steps helps you keep things moving.

Step-by-step from your side

  1. Find out early if your care needs prior authorization. Ask your providerAnyone licensed to give you medical care — a physician, nurse practitioner, or physician assistant. Clinics use "provider" as a catch-all for whoever is caring for you.‘s office and your insurer.
  2. The provider usually submits the request with supporting medical information. You generally doA medical doctor — "MD" or "DO" — with four years of medical school plus a multi-year residency in a chosen field. not submit it yourself, but you can confirm it was sent.
  3. Track the status. Ask for a reference number and a timeline. Follow up if you do not hear back.
  4. If approved, confirm what is covered and your expected out-of-pocket cost.
  5. If denied, you can appealA formal request asking your insurer to reconsider a denied claim. Many denials are overturned.. You have the right to appeal a denialWhen your insurer refuses to pay a claim. You usually have the right to appeal., and your provider can submit additional information or a “peer-to-peer” review.

What to ask

  • Does this service require prior authorization?
  • Has the request been submitted, and what is the reference number?
  • How long does a decision usually take?
  • If denied, what are my appeal options and deadlines?

A cash-pay alternative

In some cases, the cash-payPaying the provider directly instead of using insurance — often at a lower, upfront price, especially before you have met your deductible. price for a service (such as imaging) may be lower than what you would pay after insurance — and it skips the authorization wait entirely. It is worth comparing the cash price to your expected insurance cost before deciding.

Sources