Evidence-based coverage guide
Prior authorization
Identify who must request approval, what records are needed, the decision timeline, and the appeal route before scheduled care.
Prior authorization is a plan process requiring approval for certain services, drugs, equipment, or care settings before coverage under the plan's rules. Authorization is not a promise that every claim condition is satisfied.
Ask the plan and provider who submits the request, which codes and records are needed, whether an in-network provider is required, how long the authorization remains valid, and what happens if the service changes. Keep the reference number and written decision.
Verification checklist
Collect the controlling facts
- Service, drug, equipment, and billing codes
- Requesting provider and plan channel
- Clinical and administrative records
- Decision and expiration dates
- Changes requiring a new request
- Urgent review, exception, and appeal procedures
Reusable process
Turn information into a dated record
- Start at the responsible official source. Confirm the program, plan, Marketplace, or agency that controls the question.
- Match identity and date. Use the exact plan, coverage year, notice, person, service area, or program record.
- Write unknowns as unknown. Ask the responsible organization instead of filling a gap with a national average.
- Keep the documents. Save the current notice, policy, result, reference number, and the date checked.
When this topic needs another check
Review the official source again when the plan year changes, the household moves, eligibility facts change, a new notice arrives, a provider or prescription changes, or an important service is planned. Saved web pages and directories are dated evidence, not permanent promises. Keep new records beside the earlier version so a change is visible.
Verification links
Primary sources
Primary sources checked August 11, 2026. Follow the current official record for an individual decision.