How Prior Authorization Decisions Are Made

Prior authorization is a review that happens before care is delivered. It asks whether a proposed service meets the plan's criteria, not whether the clinician's judgment is sound.

Criteria are written in advance and applied by staff

Plans adopt clinical criteria, often licensed from outside vendors or developed internally, describing when a service is considered appropriate.

Initial review is typically performed by nurses or trained reviewers who compare the submitted record against those criteria and approve anything that matches.

Requests that do not match are escalated to a physician reviewer. In many arrangements only a physician may issue a denial on medical grounds.

The request is only as strong as the submitted record

Reviewers see what the ordering office sends. A note that omits prior treatments tried, symptom duration or failed alternatives fails criteria that the patient actually meets.

This is why a denial is frequently reversed on resubmission without any change in the clinical situation. The missing element was documentation.

Asking the ordering office what was submitted is more productive than asking the plan why the answer was no.

Step therapy imposes an ordering requirement

Some criteria require that a less expensive option be tried first, with failure or intolerance documented, before a requested treatment is approved.

Exceptions generally exist where the earlier option is contraindicated or has already been tried, but the exception must be requested with support.

Drug lists and the requirements attached to them are revised periodically, so a medication approved previously can require authorization later.

Turnaround times are regulated but variable

Standard and expedited timeframes are set by regulation and by plan type, with expedited review reserved for situations where delay poses risk.

Electronic submission is generally faster than fax or portal entry, and some services have moved to automated approval where criteria are clearly met.

An authorization also carries an expiry and a defined scope, so a delayed procedure may need the approval renewed.

Approval is not a payment guarantee

Authorization confirms medical necessity was accepted. Payment still depends on eligibility on the date of service, network status and correct coding.

Patients occasionally receive a denial after an approved service for one of those reasons, which is a different dispute with a different remedy.

Requirements differ across plan types and are changing as regulators press for faster decisions, so the plan's current policy document is the only reliable statement of what applies.