Prior authorization
Updated September 30, 2026
Definition
Approval from your health plan before you get certain care, drugs, or equipment. If it's required and missing, your plan may deny the claim.
Prior authorization is approval from your health plan before you get certain care. Your plan decides whether a service, treatment plan, drug, or piece of medical equipment is medically necessary. It's also called preauthorization, prior approval, or precertification. You don't need it for emergency care.
Your provider usually asks for it, but it's worth confirming it was approved before your appointment. Approval doesn't promise your plan will pay. Your benefits and coverage rules still apply.
If prior authorization was required and missing, your plan may deny the claim. Your explanation of benefits (EOB) may show reason code 197 for this. You can appeal the denial. If an in-network provider was supposed to get approval and didn't, ask the billing office whether you're responsible for the charge. Our guide to what to do when insurance didn't pay covers the next steps.
Related terms
Guides that use this term
- GuidePrior authorization denied: what to do nextPrior authorization denied? Learn why it happens, how your doctor can resubmit or ask for a peer-to-peer review, and how to appeal before your deadline.
- GuideInsurance didn't pay my medical bill: what to do nextInsurance didn't pay your medical bill? Find out why, match the denial code to the fix, and learn when to ask for a rebill and when to file an appeal.
Sources
- Preauthorization (glossary), HealthCare.gov. Accessed September 30, 2026.
- Claim adjustment reason codes, X12. Accessed September 30, 2026.
This is general information, not legal or medical advice. Rules can depend on your plan and your state. Romi Care isn't an insurer, law firm, collection agency, or government program.