WPS Health Insurance Blog

What is a health insurance pre-approval and when do I need one?

Posted by Rob Rhode

Jan 29, 2013 7:00:00 AM

Health insurance pre-approvalsPre-approval. Pre-authorization. Prior authorization. Whatever you call it, there are times you need it if you want your health insurance company to cover you.

A pre-approval is an authorization that health insurance companies require plan members to obtain before receiving certain types of care.

“Isn’t that an inconvenience?” you ask. It may be, but it’s an important precaution.

The reason insurers require pre-approvals is so they can confirm medical necessity—that the treatment prescribed by the doctor is appropriate for the patient’s condition. By confirming medical necessity, the insurer also helps to control health care costs by reducing duplication, waste, and unnecessary treatments.

Which services require pre-approval?

As a health care consumer, it is important for you to understand which services require pre-approval. If you receive care without first obtaining a required pre-approval, your insurer may not cover your claims.

Most procedures that require pre-approval go well beyond the routine care provided by your primary care physician. Some of the medical proce­dures and services for which insurers typically require pre-approval include:

  • Gastrointestinal tests (endoscopies, CT colonoscopies)
  • Home care services (home therapy, hospice, skilled nursing visits)
  • Pain management services (nerve blocks, trigger point injections, a host of others)
  • Radiology services (X-rays, CT scans, ultrasounds)
  • Sleep studies (to diagnose sleep disorders)
  • Surgical procedures
  • Non-emergency ambulance services
  • Specialty drugs provided in certain situations
  • Durable medical equipment

Inpatient hospital services are subject to pre-approval, too, although they go by a different name. Should your doctor wish to admit you for a non-emergency hospital stay, you would likely be required to obtain “pre-admission certification.” As you might guess, pre-admission certification is not required for emergency hospital stays.

Be proactive

Because every insurance contract (or “policy” or “certificate”) has its own rules, you should call your insurer to see if you need pre-approval before scheduling an appointment. Yes, oftentimes the health care provider will initiate a pre-authorization request on your behalf. But most providers partner with several different health insurers. As you can imagine, it’s not easy to stay up to date on the specifics of every plan. Ultimately, it is your responsibility to make sure approval has been granted. If it’s not, you could be responsible for the bulk of your costs.

When calling your insurance company about a pre-approval, consider asking additional questions such as:

  • How many visits are you approved for?
  • Do you need a new approval for each visit?
  • If you are going to be hospitalized or in inpatient care, how many days are you allowed to stay?

Remember, it pays to be proactive. A quick phone call could save you thousands of dollars.

If a pre-authorization is denied

Sometimes, a pre-authorization request is denied. If that happens, you have the right to appeal the decision. Follow the process set forth by your insurance company and make sure to document medical necessity with written proof (a report, lab test, X-ray, etc.) from your provider.

If you’re shopping for a plan

Are you in the market for health insurance? Pre-authorization requirements can provide a valuable point of comparison. Understanding the requirements of each of your plan options is an important step in choosing an appropriate policy with appropriate coverage.

Topics: health insurance