As a health care consumer, it is important to understand which services require prior approval, also called pre-approval, pre-authorization or prior authorization. If you receive care without first obtaining a required prior approval, your health plan may reduce your benefits or simply not cover your claims.
A prior approval is an authorization that health plans require members to obtain before receiving certain types of care. The reason prior approvals are required is so the health plan can confirm medical necessity, which means that the treatment prescribed by the doctor is appropriate for the patient’s condition. By confirming medical necessity, the health plan helps to control health care costs by reducing duplication, waste, and unnecessary treatments. The process can be inconvenient at times, but it helps keep your premium lower.
Which services require prior approval?
Most procedures that require prior approval go well beyond the routine care provided by your primary care physician. If you’re going to the hospital for an inpatient procedure, you likely need prior approval. It’s always a good idea to call your health insurer and ask. Some of the medical procedures and services for which WPS individual health plans typically require prior approval include (these don’t apply to all plans, so check your plan for details):
- Intravenous therapy/infusion therapy performed in your home when prescribed by a physician
- Transplant services
- Non-emergency licensed professional ambulance services
- Any prosthetic with a total purchase price greater than $1,000
- Any durable medical equipment that will be rented for more than three months or with a total purchase price greater than $500
- Certain pain management procedures
- Genetic testing services for treatment of an illness
- Specialty drugs provided by a health care provider other than a pharmacy (e.g. physician’s office, outpatient department of a hospital, kidney dialysis facility, licensed skilled nursing facility, or home health agency)
Inpatient hospital services are also subject to another process. If your doctor wants to admit you for a non-emergency hospital stay, you would likely be required to obtain “pre-admission certification.” Pre-admission certification is not required for emergency hospital stays.
Because every health plan has its own rules, you should call your insurer to see if you need prior approval before scheduling an appointment. Many times, the health care provider will initiate a prior 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.
Find out more
Are you in the market for health insurance? Prior approval and pre-admission requirements can provide a valuable point of comparison among plans. Understanding the requirements of each plan’s options is an important step in choosing an appropriate policy with appropriate coverage. Read all about other health plan features to consider in our Learning Center.