What is a Pre-Authorization?
A pre-authorization, also called a prior authorization, is a requirement from your insurance provider that certain medical services must be approved before you receive care. It’s their way of confirming that the service is medically necessary and covered by your plan.
Pre-authorizations are not a guarantee of payment. It is simply a key step to avoid having a claim denied later.
Why Are Pre-Authorizations Important?
If your insurance requires a pre-authorization and it isn't obtained in advance, you could be responsible for paying out of pocket, even if the service is normally covered. That’s why it’s critical to check with your insurance before your appointment.
Confirming When a Pre-Authorization is Needed
Call the member services number on the back of your insurance card.
Ask: “Does my plan require a prior authorization for outpatient mental health services with [Practice Name]?”
If yes, find out who is responsible for submitting the request: you, your primary health provider, or both.
Common Scenarios That Will Require Pre-Authorizations
Pre-authorizations are typically required under the following circumstances:
Certain types of therapy or assessments,
Certain types of prescriptions and durable medical equipment,
Ongoing or frequent visits,
Specialist services, and
Higher-cost procedures.
Helpful Tips on Pre-Authorizations
Approval can take anywhere from a few days to a couple of weeks.
It’s best to confirm well in advance of your appointment date.
Even if you’ve received care before, your insurance may re-evaluate pre-authorization needs each year or when your plan changes.
Using Insurance for Behavioural Health & Sleep Services
While we do our best to make care seamless, insurance coverage for Behavioral Health (like ADHD, anxiety, and depression) and sleep apnea evaluations can sometimes come with extra steps.
Does Insurance Always Cover These Appointments?
Rest assured, many insurance plans do cover these services, but restrictions may apply. Here’s what you might encounter:
Prior Authorizations: Some plans require pre-approval before covering care like ADHD evaluations or sleep studies. Without it, your claim may be denied, even if the service is technically covered.
Coverage Limits: Certain mental health services may only be covered for specific diagnoses or require you to meet a deductible first.
Telehealth Exclusions: Not all plans cover virtual appointments, particularly for sleep testing. Always check if your plan allows telemedicine for the service you’re seeking.
Network Restrictions: Even if we accept your insurer (like Aetna, Cigna, or Anthem), your specific plan may require you to see providers in a narrower network.
Confirming Coverage Before You Book
📞 If you think your care may involve any of the services listed above, call your insurance provider before booking an appointment and ask:
“Is [Service Type] covered via telehealth?”
“Do I need a prior authorization?”
“Is [Practice Name] in-network under my specific plan?”
Getting clarity upfront can save you time, money, and stress.