If you have ever been told a test, treatment, prescription, or procedure needs “prior authorization,” you are not alone.
This is one of the most common reasons employees run into delays with care. It is also one of the most misunderstood parts of health insurance. Prior authorization, sometimes called preauthorization, prior approval, or precertification, is when a health plan requires approval before certain services, medications, or equipment will be covered. It is important to know that prior authorization is not the same thing as a guarantee of payment. Even when approval is given, the service still has to meet the terms of the plan, including eligibility, benefits, and network rules.
For employees, the hardest part is often timing. Prior authorization usually happens before care is provided, which means delays can affect when you can schedule treatment, pick up a prescription, complete imaging, or move forward with a specialist’s recommendation. Washington State has modernized its prior authorization rules to help reduce delays in care, and the Office of the Insurance Commissioner says those updates took effect January27, 2025.
What prior authorization usually applies to
Not every service needs prior authorization. Requirements vary by carrier and plan, but it often comes up for things like advanced imaging, certain surgeries or outpatient procedures, specialty medications, infusion drugs, durable medical equipment, and some higher-cost or ongoing treatments. Federal consumer glossary materials also note that preauthorization may apply to a health care service, treatment plan, prescription drug, or durable medical equipment.
This is one reason employees can feel blindsided. A doctor may recommend care, but the plan may still require an extra review step before it will cover that care.
Why prior authorization causes delays
In many cases, the employee is not the one actually submitting the request. The provider’s office usually handles it, but the process still depends on accurate plan information, correct coding, supporting medical records, and confirmation that the service is being requested under the right benefit and network. CMS describes prior authorization as a process that happens before services are rendered, and Washington’s rulemaking specifically states that the modernization effort was intended to prevent delays in care and improve health outcomes.
Delays can happen when:
- the provider’s office does not yet have the full clinical notes
- the wrong health plan information is used
- the service is out of network
- a step therapy or alternative treatment rule applies
- the request is incomplete
- the employee assumes approval is automatic and schedules too soon
Prior authorization problems are not rare. KFF found that16% of insured adults reported prior authorization problems in the past year, and those problems were associated with delayed or denied care, declining health status, and higher out-of-pocket costs.
What employees can do before care is scheduled
Employees cannot always control the full process, but they can make it smoother.
1. Ask early whether prior authorization is required
Do not assume the provider or facility has already checked. Ask the provider’s office and the carrier whether the specific service, medication, or equipment requires prior authorization under your exact plan.
2. Confirm the provider and facility are in network
A service can run into issues not only because of prior authorization, but because the location or provider is out of network. Confirm both before the appointment whenever possible.
3. Ask who is submitting the request
Usually the provider handles this, but it is smart to confirm which office is responsible and when they expect to send it in.
4. Verify what information the plan needs
Some requests are delayed simply because clinical notes, chart documentation, or codes are missing.
5. Do not confuse scheduling with approval
A service being placed on the calendar does not always mean authorization is complete.
6. Keep records
Write down the date, the name of the provider office or carrier representative, and what they told you. If a problem comes up later, that timeline matters.
How long does prior authorization take?
Timeframes depend on the type of request and the type of coverage involved. Under the 2024 CMS Interoperability and Prior Authorization final rule, certain impacted payers must send prior authorization decisions to providers within 72 hours for expedited requests and within 7 calendar days for standard requests. CMS also requires certain payers to publicly report prior authorization metrics beginning in 2026.
Washington also updated state prior authorization rules through its modernization effort, with the Office of the Insurance Commissioner stating that the adopted rule updates prior authorization time frames for health care services and prescription drugs and clarifies plan applicability standards.
For employees, the practical takeaway is simple: ask whether the request is urgent, when it was submitted, and when a determination is expected.
Does prior authorization apply in emergencies?
Generally, emergency services are treated differently. Federal guidance explains that plans cannot require prior authorization for most emergency services in the way they do for many non-emergency services.
That said, follow-up care after the emergency may still involve network, referral, or prior authorization questions depending on the plan.
What if prior authorization is denied?
A denial does not always mean the conversation is over.
Washington’s Office of the Insurance Commissioner makes clear that when a health insurer says no to a treatment or bill dispute, you have the right to appeal. The OIC also provides resources on how to appeal a health insurance denial, common denial reasons, and where to go depending on what kind of plan you have. For employer health plans, where you go for help may depend on whether the plan is fully insured or self-funded.
If a prior authorization is denied, employees should:
- ask for the reason in writing
- request a copy of the denial notice
- ask the provider whether additional documentation could support the request
- review the plan’s appeal instructions
- involve HR or the benefits contact if help is needed understanding next steps
- reach out to the appropriate regulator or plan contact if the issue is not being resolved
A better employee mindset around prior authorization
Prior authorization is frustrating, but employees are in a stronger position when they know it is a process step, not a signal that car is impossible.
The best approach is to ask early, verify details, follow up before the appointment date, and keep written notes. That can reduce confusion, avoid preventable delays, and help employees move faster if an appeal or escalation becomes necessary.
At Maddock & Associates, this is one more reason benefits education matters. When employees understand how coverage works before a problem happens, they are better prepared to navigate the system with less stress and fewer surprises.
Need help understanding how common benefits processes work? Explore more practical employee guidance in the Maddock & Associates News & Resources library.
