What prior authorization actually decides

Prior authorization is the plan’s decision, made before a stay, a procedure, or a drug, about whether that item will be treated as eligible under the plan’s rules. It decides eligibility for coverage under those rules. It does not send a payment, and it does not replace the claim that is filed after the service.

What the notice decides

An approval means the plan accepted the request under the rules it applied at that time. Cost sharing can still apply. A denial means the plan refused that request. The denial letter or portal notice is the document that starts the appeal timeline. A denial is not a closed file.

The usual mix-up

People treat an approval as a promise that nothing will be owed, or treat a denial as the end of the matter. Approval is not payment. Denial is the start of the appeal process the plan’s rules describe.

A clinic can say a request was approved while the plan says it never received one. Those are two different records.

What to read on the document

Keep the authorization number with the date of service. When the explanation of benefits posts, match that number to the claim. If the clinic’s record and the plan’s record disagree, ask which document they will put in writing. For a denial, read the reason code and the appeal deadline on the notice the plan sent.

Educational only · Not medical, insurance, or legal advice