Prior authorisation (often shortened to “prior auth” or “PA”) is a requirement from a health insurance payer that a healthcare provider must obtain approval before performing a specific service, procedure, or prescription. The insurer reviews the request to determine whether the treatment is medically necessary and covered under the patient’s plan.
If the provider doesn’t get prior auth for a service that requires it, the insurer may deny the claim, leaving the patient or provider to cover the cost.
You’ll hear this when…
Prior auth is one of the most discussed — and frequently criticised — processes in healthcare. Providers deal with it daily. Common triggers include advanced imaging (MRIs, CT scans), specialty medications, surgical procedures, and referrals to out-of-network specialists.
“We’re waiting on prior auth” is a phrase patients hear regularly. The process can take days to weeks, and delays in prior auth can delay treatment.
In health-tech, prior auth automation is a significant product category. Startups and established companies alike are building tools to streamline what is, in many practices, still a manual process involving phone calls and fax machines.
The tension
Payers argue prior auth controls unnecessary spending and prevents harmful overtreatment. Providers argue it adds administrative burden, delays care, and sometimes overrides clinical judgement. The American Medical Association has called for significant reforms to the process.
Source: American Medical Association (AMA) prior authorisation reform advocacy; CMS regulatory guidance