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Health Insurance Basics

How Can Health Insurance Preapproval Help You Make Informed Healthcare Decisions

July 28, 2017

Most people want to know all their options before they make important health care choices. That's why your plan offers you a preapproval benefit. Preapproval also has other names; some providers call it pre-authorization, prior authorization or precertification. This benefit allows your plan to review treatment, devices or medicines you're considering and inform you about other options you might prefer.

When Is Preapproval Required?

You won't need to use your preapproval benefit for all the care you receive. It's only appropriate when you're making a major healthcare decision.

Some health insurance plans require preapproval for some types of treatments, devices, and medications. Here are a few examples of situations when preapproval might be required, depending on the type of plan you have:

  • You've been told you may need to stay overnight in a hospital.
  • You've been told you may need major surgery.
  • You've been prescribed drugs that are costly or could have serious side effects.
  • You've been referred to a physical, occupational, behavioral, or speech therapist for treatment.

Getting preapproval doesn't mean your plan will pay for the services you receive. It only means that you've appropriately notified your plan and obtained authorization for that treatment or prescription. If you don't get preapproval when it's required, your plan might not cover those services. Instead, you could be financially responsible for the full cost.

How to Get Preapproval

Many hospitals, labs, pharmacies, doctors' offices, and other health care providers in your plan’s network will contact your plan and get preapproval for you. If an issue comes up that you need to consider, your provider will let you know.

If your provider isn't in-network for your plan or you'd like to find out on your own whether preapproval is recommended for care you expect to receive, you can contact your plan by phone or online and ask. You may need to fill out a form that explains why you need the treatment, lab tests, drugs, or other services. You'll also be able to find out from your plan whether other options might be suggested for you.