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Healthcare Asks: What is Prior Authorization?

February 15, 2024

In our Healthcare Asks series, we ask healthcare industry experts some of the most common healthcare questions we hear from members. For more straight answers to your healthcare questions, check out the Healthcare Asks playlist on YouTube. And don’t forget to subscribe to our channel while you’re there!

Prior authorizations, sometimes also called preapprovals, can be confusing and frustrating for members. But these processes, which are common across all health plans, are necessary to ensure the treatment members have been prescribed is medically necessary and is the proper care.

Prior authorization is an important tool to ensure that the services, drugs, and devices patients receive are supported by current, credible medical evidence and are administered by a clinician with the appropriate expertise and training.

Premera’s medical director, Dr. Josephine Young, explains more about the process, and why it’s needed, in the video below.

To help determine if a medical procedure is appropriate, a team of experienced doctors, nurses, and healthcare analysts reviews each prior authorization request. It’s their goal to make sure clinical best practices are being followed and that every member is getting the care they need at an affordable cost.

Some common services that require prior authorization are:

  • Planned admission into hospitals or skilled nursing facilities
  • Some inpatient surgeries
  • Non-emergency ground or air ambulance transport
  • Advanced imaging, such as MRIs, CT scans, and cardiac imaging
  • Transplant and donor services
  • Some planned outpatient procedures and surgeries

This is not a complete list, but your doctor has the current list needed to request a prior authorization on your behalf.

By ensuring a given treatment or procedure is medically appropriate, the prior authorization process helps members:

  • Make sure they understand their benefits and the costs involved before they have a procedure
  • Save money and avoid extra costs
  • Get an estimate of their out-of-pocket costs
  • Avoid inappropriate or unnecessary medical treatments or services