What is the No Surprises Act?

The No Surprises Act helps protect you from surprise medical bills in many situations. A surprise medical bill can happen when you get care from an out-of-network provider or facility and have to pay more than expected. This is also called balance billing. The law bans surprise bills for most emergency services, even if you get them out-of-network and without prior authorization. This includes most emergency care, some nonemergency care from out-of-network providers at in-network facilities and some air ambulance services.

What is prior authorization in health insurance?

Before you get some types of care, your health plan may need to review it first. This is called prior authorization.

Your health plan checks for coverage before you get care. This may help you avoid surprise costs. It may also help make sure the care is needed.

Most care does not need prior authorization. But when it is needed, it helps to know how it works, why it may be required and how the process is being improved.

What is prior authorization?

Prior authorization is a process that starts before care is delivered. It is also known as preauthorization, prior approval or precertification. Prior authorization is a decision by your health plan that a health care service, treatment plan, prescription drug or durable medical equipment (DME) is medically necessary.

Why is prior authorization required?

Sometimes your doctor may recommend care that needs to be reviewed first. In these cases, your doctor asks your health plan to approve the care before you get it. This helps your plan check if the care is:

Medically needed
Treatment you haven’t already tried
An option that's both effective and lower in cost

Prior authorization can help make sure care is safe, covered and needed. It may also help lower your health care costs.

How can prior authorization help save you money?

Prior authorization may help find lower-cost drugs that can treat the same condition. These options may help lower your costs while still giving you effective treatment.

How does prior authorization work?

Your doctor may ask your health plan to approve some care before you get it. Your health plan reviews the request to see if the care is covered and meets quality and safety standards.

Prior authorization decisions are based on medical evidence. If a request is not approved right away, a qualified clinician reviews it. This may include a pharmacist or doctor.

Clinical review rules are typically based on FDA-approved drug information, safety details, medical and pharmacy research, treatment guidelines and other trusted clinical resources.

What should you do if your doctor or pharmacy says prior authorization is required?

If a treatment or service needs prior authorization, your doctor sends a request to your health plan. You may need to help by filling out forms or sharing documents. Then your plan decides how or if they will cover it. Clinicians at your health plan will review the request.

How long does the prior authorization process take?

Rules on how long prior authorizations take vary by state. If care is urgent, many states require the health plan to reply within 1 to 3 days. If care isn’t urgent, states require the health plan to reply within 2 to 15 days.¹

Check your state’s rules or ask your health plan what to expect. Your doctor’s office may also be able to tell you how long it could take.

What treatments, services and medications may require prior authorization?

It depends on your health plan. High-cost care is more likely to need this step.

Prior authorization is often used in 3 situations:

When there is more than one treatment option
When care guidelines change
When care may cost a lot

Treatments and services that commonly need prior authorization may include high-cost and specialty drugs, advanced imaging, mental health and substance use disorder services, elective surgeries and DME.²

Your health plan has a list of drugs and services that may need prior authorization. You can typically find this list in your plan documents or online. You can also use your Prescription Drug List (PDL). A PDL, also called a formulary, is a list of commonly used medications, organized into cost levels, called tiers. These costs are decided by your employer or health plan. View your PDL to learn what’s covered by your plan.

Hospital visits and location authorization

Your health plan may ask you to get care at certain hospitals or clinics. These are usually places that have a payment agreement with your health plan.¹

Why do some prescription medications require prior authorization?

Some prescription drugs need prior authorization before your plan helps pay for them. This step helps check that the drug is safe, needed and covered by your plan. For example, some long-acting opioids may need prior authorization to make sure they are being used the right way.

Most pharmacy claims are checked right away and do not need prior authorization. Your plan can quickly check if you are eligible, if the drug is on your PDL and if other rules apply.

Medications that do not need prior authorization typically include drugs for high cholesterol, high blood pressure, asthma, depression, substance use disorders, diabetes and many other conditions.

How prescription prior authorization works

Prior authorization means your health plan needs to approve some medications before it helps pay for them. For prescription drugs, the pharmacy typically sends a claim first. The health plan system will often check it right away. It looks at things like your eligibility, whether the drug is on your PDL, safety limits and prior authorization rules. If prior authorization is needed, the process starts then.

What to do if your medication requires prior authorization

You may not know prior authorization is needed until you try to fill your prescription. If it is needed, your health plan tells the pharmacist. Some medical record systems can connect with health plan systems.¹ Sometimes the system can approve the prescription automatically.

When prior authorization is needed, the health plan may use information it already has to review the request faster. Some requests can be approved without asking the doctor for more information.

If more review is needed, the pharmacy, your doctor or you may need to send a request to your health plan. How long it takes depends on your plan, the type of request and required timelines. Many prior authorizations are confirmed quickly.

What happens if a prior authorization is denied?

If your prior authorization is denied, you can appeal. Talk with your doctor about the next steps. Your doctor may need to explain why the drug is needed, why other covered options may not work or why the drug may be safer or more effective for you. Lab results, imaging results or other health information may also be needed.

If the appeal is denied, your doctor may suggest another treatment. For example, your plan may approve a preferred biosimilar instead of another drug, if it meets medical guidelines. Or your plan may approve a change that fits your benefits. For example, your plan may require one higher-strength pill instead of 2 lower-strength pills if it can help lower your cost.

In some cases, you may need to try a lower-cost choice first. If that treatment does not work, your doctor may be able to request the original treatment again. About 4 out of 5 appeals end up overturning a prior authorization denial.¹

These steps can help you get care that follows medical guidelines and may cost less.

Do you need prior authorization in emergencies?

If your plan covers emergency care, it cannot require prior authorization for emergency medical care, even if the hospital or provider is out of network.

Prior authorization only applies to planned services and is never required for emergencies or urgent care.

Are you a member looking for information about your plan?

Sign in or register for a member account to view your PDL, find prior authorization forms, search for network providers, manage prescriptions, view plan spending, find copays and more.

Frequently asked questions about prior authorization

No, prior authorization isn't a promise your health plan will cover the cost.

The Centers for Medicare & Medicaid Services (CMS) has programs to help people get medically needed care and reduce incorrect Medicare billing and payments. CMS uses prior authorization and pre-claim reviews to help make sure Medicare rules are followed.³

The No Surprises Act helps protect you from surprise medical bills in many situations. A surprise medical bill can happen when you get care from an out-of-network provider or facility and have to pay more than expected. This is also called balance billing.⁴

The law bans surprise bills for most emergency services, even if you get them out-of-network and without prior authorization.

This includes most emergency care, some nonemergency care from out-of-network providers at in-network facilities and some air ambulance services.

You can typically find prior authorization forms in your health plan’s member portal. Your doctor’s office may also be able to submit the request for you. You could also call the number on your member ID card to ask where to send the form.

UnitedHealthcare members can sign in to your member account or the UHC app to see your health plan details and find member forms.

Your doctor can start the prior authorization process. Or you can call the number on your member ID card and your health plan will contact your doctor.

Sometimes a provider can ask for a faster prior authorization review. Some provider groups also participate in the UnitedHealthcare Gold Card program. This program offers a simpler approval process for certain procedures.