An authorization in healthcare is an approval from your insurance company that must be obtained before you receive certain medical services or fill certain prescriptions. Without it, your plan may refuse to cover the cost, leaving you responsible for the full bill. Most people encounter authorizations (formally called “prior authorizations”) when their doctor recommends a procedure, specialist visit, imaging scan, or medication that the insurer wants to review before agreeing to pay.
Why Insurers Require Authorizations
Insurance companies use prior authorization as a gatekeeping tool to manage costs and, in theory, ensure treatments are medically appropriate. The stated goal is to verify that a recommended service is necessary, that it matches current clinical guidelines, and that a less expensive alternative isn’t equally effective. The American Medical Association has pushed back on this framing, noting that cost-containment measures without proper medical justification can put patient outcomes in jeopardy. In practice, prior authorization sits at the center of an ongoing tension: insurers see it as responsible oversight, while many physicians view it as a barrier that delays care.
What Services Typically Need Authorization
Not every doctor visit or prescription triggers an authorization. Insurance plans generally require them for higher-cost or more complex items. Common categories include:
- Advanced imaging: MRIs, CT scans, PET scans
- Surgical procedures: joint replacements, spinal surgeries, cataract removal
- Specialty medications: biologics, cancer drugs, high-cost injectables
- Durable medical equipment: power wheelchairs, hospital beds, prosthetic limbs, compression devices
- Mental health and substance abuse treatment: inpatient rehab, intensive outpatient programs
- Out-of-network referrals: seeing a specialist outside your plan’s network
The specific list varies by insurer and plan. Medicare, for example, maintains a required prior authorization list for items like microprocessor-controlled prosthetic knees, powered air flotation beds, and power mobility devices. Your plan’s member handbook or the insurer’s website will list exactly which services need approval.
How the Process Works
The process usually starts with your doctor’s office, not with you. After your provider determines you need a particular service, their staff submits a request to your insurance company. That request includes clinical documentation explaining why the service is medically necessary: your diagnosis, relevant test results, treatment history, and the specific procedure or drug being recommended.
The insurer then reviews the submission against its coverage criteria. A nurse reviewer or medical director at the insurance company evaluates whether the request meets the plan’s guidelines. If everything checks out, the insurer issues an authorization number and specifies a date range during which the approved service must be completed.
If the insurer needs more information, they may send the request back to your doctor’s office, which adds time. AMA survey data shows that physician practices complete an average of 39 prior authorization requests per physician, per week, which gives a sense of how much administrative volume these offices are managing alongside patient care.
How Long It Takes
Turnaround times depend on your insurer and whether the request is urgent. Under a CMS rule taking effect in 2026, payers covering Medicare Advantage, Medicaid, and marketplace plans will be required to respond within 72 hours for urgent requests and 7 calendar days for standard, non-urgent requests. Currently, timelines vary widely. Some authorizations come back in a day or two, while others drag on for weeks, particularly if the insurer requests additional documentation.
If your situation is clinically urgent, your doctor can flag the request as expedited. Insurers are required to fast-track these cases, though what “fast-track” means in practice differs by plan and state regulation.
Step Therapy: A Related Requirement
Step therapy is a specific type of prior authorization applied to medications. Sometimes called “fail first,” it requires you to try a less expensive drug before your insurer will approve coverage for the one your doctor originally prescribed. For instance, if your doctor prescribes a newer, brand-name medication, your plan might require you to first try a generic alternative and document that it didn’t work or caused side effects. Only after that “failure” will the plan authorize the preferred drug. CMS defines step therapy as a process that “begins medication for a medical condition with the most preferred drug therapy and progresses to other therapies only if necessary.”
What Happens When a Request Is Denied
Denials are common, and they don’t have to be the final answer. When an insurer denies an authorization, they are legally required to tell you and your doctor why. Starting in 2026, payers must provide a specific reason for every denial, regardless of how the request was submitted.
You have two levels of appeal available. The first is an internal appeal, where you ask the insurance company itself to take a second look at the decision with a full and fair review. If the situation is urgent, the insurer must expedite this internal process. If the internal appeal is also denied, you can request an external review, which sends the case to an independent third party who is not employed by your insurance company. At this stage, the insurer no longer has the final say. External reviewers often overturn denials, especially when strong clinical documentation supports the original request.
More than one-quarter of physicians surveyed by the AMA reported that prior authorization has led to a serious adverse event for a patient in their care. That statistic underscores why pushing back on denials matters when you and your doctor believe the recommended treatment is the right one.
What You Can Do as a Patient
Your doctor’s office handles most of the authorization paperwork, but you’re not powerless in the process. A few practical steps can help things go smoothly.
Always give your provider’s office your current insurance card and let them copy both sides. Insurance details change more often than people realize, and outdated information is one of the most common reasons for processing delays. Ask your provider’s office whether the recommended service requires prior authorization before you schedule it. If it does, confirm that the request has been submitted and ask for the authorization number and approved date range once it comes through.
Find out your estimated out-of-pocket costs before the service happens. An authorization means your insurer agrees to cover the service under your plan’s terms, but it doesn’t mean the service is free. You may still owe a copay, coinsurance, or charges toward your deductible. For surgeries, remember that costs can include separate charges for the facility and anesthesia, not just the surgeon’s fee.
Changes Coming in 2026
CMS finalized a rule that will reshape the authorization process for Medicare Advantage, Medicaid managed care, and marketplace plans. Starting January 1, 2026, affected insurers must meet the 72-hour and 7-day response deadlines described above. They must also give specific denial reasons to providers, report prior authorization metrics publicly on their websites, and build electronic systems that allow authorization requests to flow faster between provider offices and insurance companies. The public reporting requirement means you’ll be able to see data on how often a given insurer approves or denies requests, creating new transparency in a process that has historically been opaque.