Let’s face it—health insurance can be confusing, especially when terms like prior authorization come up. But don’t worry, we’re here to make it simple.
Prior authorizations are a common part of many health plans, meant to help ensure you get the right care at the right time. Explore the sections below for a closer look at what they are and how they work.
What is a Prior Authorization?
What is a Prior Authorization?
A prior authorization (also called pre-authorization or “PA”) is an approval from your insurance company that is often required before certain services, prescriptions, or equipment will be covered.
If a PA is required and not obtained, you could be responsible for the full cost—even if the service is usually covered.
That’s why it’s important to confirm with your insurance before receiving care, including appointments, filling prescriptions or ordering equipment.
If you are uninsured or choose to pay in cash, then you do not need to worry about prior authorizations.
Common Scenarios That May Require a Prior Authorization
Common Scenarios That May Require a Prior Authorization
You may need a prior authorization for:
Behavioral health services (e.g., ADHD evaluations, depression/anxiety care),
Sleep-related services (e.g., sleep studies, CPAP equipment),
Weight loss services (e.g., certain appointments, prescriptions, or programs),
Specialty visits, ongoing treatment, or high-cost procedures,
Certain prescriptions or durable medical equipment (DME),
Brand-name drugs when generic options exist,
Even if you’ve previously received coverage, a prior authorization may expire or be required again due to policy rules or plan-year resets.
Planning Ahead: Confirming When a Prior Authorization is Needed
Planning Ahead: Confirming When a Prior Authorization is Needed
Call the member services number on the back of your insurance card before booking care or filling a prescription.
Ask:
“Does my plan require a prior authorization for [service or medication] with [Practice Name]?”
“Is this covered via telehealth?”
“Is [Practice Name] in-network for my plan?”
If your plan requires it, confirm how long the prior authorization is valid and whether renewals are needed.
Helpful Tips on Prior Authorizations
Helpful Tips on Prior Authorizations
PAs can take several days to weeks for insurance to approve—start early.
Plans may reevaluate PA needs annually, when benefits change, or when an existing PA expires.
Just because your provider believes a service is medically necessary does not guarantee your insurance will agree. Insurance decisions are based on your plan's criteria, not solely on your provider’s recommendation.
Our role is to submit the most complete and current medical information possible, but if that info doesn’t meet your plan’s criteria, coverage may be denied.
Other Issues You May Run Into
While many insurance plans do cover the services we provide on our platform, restrictions may apply. Here’s what you might encounter:
Prior Authorizations: Some plans require pre-approval before covering care like ADHD evaluations, weight loss services, 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.
If a Prior Authorization is Denied
If a Prior Authorization is Denied
You always have the right to appeal your insurance’s decision. However, appeals are only successful if:
We can submit new documentation that meets criteria, or
We can provide a strong case for why your care should qualify, even if criteria aren't fully met.
Remember, if your prior authorization request is denied and deemed as “not medically necessary,” that judgment comes from the insurance company—not from us. We advocate for your care, but final coverage decisions rest with your insurer.
Taking these steps up-front can help you avoid surprise costs, delays, or denied claims.