What happens if prior authorization is not obtained?

Asked by: Letitia Sipes  |  Last update: July 16, 2025
Score: 4.2/5 (67 votes)

No authorization means no payment. Insurers won't pay for procedures if the correct prior authorization isn't received, and most contracts restrict you from billing the patient. PA denials result in lost revenue, declines in provider and patient satisfaction, and delays in patient care.

What happens if a doctor doesn't get prior authorization?

If you do not get prior authorization first, your insurance company may deny payment after the fact.

Who is responsible for obtaining preauthorization?

How do I get a prior authorization? If your health care provider is in-network, they will start the prior authorization process. If you don't use a health care provider in your plan's network, then you are responsible for obtaining the prior authorization.

Whose responsibility is to obtain authorization?

Your doctor's office is responsible for obtaining prior authorization. They will submit a request to your insurance provider to get approval, whether it's for a service or for a medication. Usually, your physician will have a good idea of whether they need to get prior authorization.

What is the proper response to a failure to obtain preauthorization?

The proper response to a failure to obtain preauthorization denial is to request a retrospective review. This type of review occurs after the medical service has been provided, and it involves the insurance company evaluating the claim to determine if it meets the necessary criteria for coverage.

How Prior Authorization Denials Happen

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What percent of prior authorizations are denied?

More than a quarter of physicians (27%) reported prior authorization requests are often or always denied, and more than four in five (87%) reported prior authorization requirements lead to higher overall use of resources that result in unnecessary waste.

Can you bill a patient if a claim was denied for no authorization?

If you fail to go through preapproval as outlined in your contract and then the payer denies the claim, you can't pass the costs on to the patient, since you missed a step in the billing process.

What happens if the authorization is denied?

If your request for prior authorization is denied, then you and your patient will be notified about the denial. The first step is to understand the reason behind the denial, so contact the health insurance company to find out the problem. For example, a PA request for a medication might be rejected due to many reasons.

Can a doctor's office charge for prior authorization?

Physicians and other healthcare providers do not usually charge for prior authorizations. Even if they wanted to, most contracts between providers and payers forbid such practices. However, there are some instances — such as when a patient is out of network — that it may be appropriate to charge for a prior auth.

Can I call my insurance about a prior authorization?

The patient or their representative can contact their insurance company and provide the relevant information to start the Prior Authorization process. It's best to confirm with the healthcare provider if they have the information and are willing to submit the request.

What does it mean when a prior authorization is not required?

This means the plan does not require prior authorization or premedical review. In these cases, it is going to be up to the physician or physician practice to decide if the patient meets the payor guidelines per local coverage determination policies.

Who denies prior authorizations?

An insurance reviewer will look at what treatments or medications are being requested and review the records submitted. The reviewer decides if the insurer will approve or deny the prior authorization.

Who handles submitting a request for prior authorization?

Under prior authorization, the provider or supplier submits the prior authorization request and receives the decision before services are rendered.

Can I get a prescription without prior authorization?

Prior authorization requires your doctor or provider to obtain approval from your health plan before providing health care services or prescribing prescription drugs. Without prior authorization, your health plan may not pay for your treatment or medication. (Emergency care doesn't need prior authorization.)

Which health insurance company denies the most claims?

According to the analysis, AvMed and UnitedHealthcare tied for the highest denial rate, with both companies denying about a third of in-network claims for plans sold on the Marketplace in 2023, respectively.

Why is it so hard to get a prior authorization?

Insurance companies can deny a request for prior approval for reasons such as: The doctor or pharmacist didn't complete the necessary steps. Filling the wrong paperwork or missing information such as service code or date of birth. The physician's office neglected to contact the insurance company due to a lack of time.

What happens if prior authorization is denied?

If You Have a Fully-insured Policy

The next step is to resubmit the authorization. For the resubmission process, you will need to know why you were denied. Do not be afraid to call your contact and ask for a detailed explanation in writing as to why you were denied. Once you receive the explanation, read it carefully.

How long do prior authorizations last?

This can depend on how urgently the medication is needed, the complexity of the paperwork that needs to be filled out and how fast your insurance carrier is in completing the review. Once approved, the prior authorization typically lasts for 12 months.

How do I fight a denied prior authorization?

You may also file an appeal if your health plan denies pre-approval (called prior authorization) for a benefit or service. There are two types of appeals—an internal appeal and an external review. You file an internal appeal to ask your health plan to review its decision to deny a claim.

Can patients do their own prior authorization?

Some plans allow patients to file their own prior authorizations, but most often this is a process that must be initiated with the doctor's office. Often your doctor will have an idea that the healthcare you need is likely to require this extra step.

What is required authorization not obtained?

What Is a “Required Authorization Not Obtained” Chargeback? If a business receives a reason code 4808 chargeback, it simply means an authorization-related error was cited as the reason for the chargeback. In other words, authorization for the transaction in question was required, but was not properly obtained.

Can you appeal for no prior authorization?

Aim to include the following details in your appeal letter:
  • the patient's name and policy number.
  • the authorization number or claim number assigned by the payer.
  • the date of your initial prior authorization request and the intended date of service.
  • the denial reason you received from the payer.

Which of the following cases is patient authorization not needed?

A covered entity is permitted, but not required, to use and disclose protected health information, without an individual's authorization, for the following purposes or situations: (1) To the Individual (unless required for access or accounting of disclosures); (2) Treatment, Payment, and Health Care Operations; (3) ...

How to speed up prior authorization for medication?

These are 13 practical tips to accelerate prior authorization for medication:
  1. Create a Master List of Medications That Require Prior Authorization.
  2. Document Denial Reasons Thoroughly.
  3. Stay Informed of Industry Standards & Payer Requirements.
  4. Assign a Dedicated Team for Managing Prior Authorizations for Medication.