Prior Authorization and Referrals: A Practical How-To

Some care needs your insurer's OK before the plan will pay for it. That's prior authorization. It's separate from a referral — a referral is your primary care doctor sending you to a specialist. They're different permissions, from different people, and you can need both. Here's how to handle each without surprises.

What prior authorization is

Before certain services, drugs, or equipment are provided, your insurer reviews the request to confirm it's medically necessary and covered under your plan. Only after approval does the plan agree to pay its share.

Why insurers require it: to confirm the care is appropriate, to manage costs, and sometimes to steer toward an equally effective lower-cost option first. Whether you agree with the practice or not, the requirement is real — and getting care without a required authorization can mean the plan refuses to pay.

What often needs prior authorization

Every plan has its own list, but these commonly require it:

• Imaging like MRIs and CT scans
• Surgeries and outpatient procedures
• Hospital admissions
• Certain prescription drugs (especially expensive or specialty ones)
• Durable medical equipment (wheelchairs, oxygen, CPAP machines)

"Often" is doing real work in that list. Your plan's documents — or a call to the number on your insurance card — are the only definitive source for what your plan requires.

Referrals vs. prior authorization

The key point: a referral gets you to the specialist; prior authorization gets the service covered. One doesn't replace the other.

The practical how-to

1. When your doctor recommends a service, ask two questions: "Does my plan need prior authorization for this?" and "Does my plan need a referral?" Ask both — the answers are independent.
2. Ask who files it. Prior authorization is usually filed by your doctor's office, not by you. Referrals come from your primary care doctor. But "usually" isn't "always" — confirm.
3. Get a reference or confirmation number, plus the name of everyone you speak with, and the date. Write it down.
4. Ask how you'll be notified of the decision — and what to do if you haven't heard back before your appointment date. Don't assume silence means approval.
5. Build in time. Authorizations take time to process, so start early when care is scheduled. We don't publish insurer-specific timelines; ask your plan and your doctor's office directly.
6. Emergency care doesn't wait. Prior authorization isn't required before emergency treatment — get the emergency care first.

If it's denied or dragging

You have appeal rights, and they work. Start with your plan's internal appeal process, and if that doesn't resolve it, you may be able to request an independent external review. The full ladder — including who handles external review in Tennessee — is on our appeals page. Throughout, keep copies of everything and note names, dates, and reference numbers for every call.

Frequently asked questions

What is prior authorization? Your insurer's advance approval for a specific service, drug, or piece of equipment — a check that it's medically necessary and covered before the plan agrees to pay.

Is a referral the same thing as prior authorization? No. A referral is your primary care doctor sending you to a specialist (typical with HMOs). Prior authorization is your insurer approving the service itself. You can need both.

Who is responsible for getting prior authorization — me or my doctor? Usually your doctor's office files the request with your insurer. But confirm this every time — don't assume it was filed, and ask for the reference number.

What happens if I get care without a required prior authorization? The plan can refuse to pay, leaving you with the bill. This is the expensive mistake this page exists to prevent.

How long does prior authorization take? It varies by plan, service, and urgency. We don't publish insurer-specific timelines — ask your plan directly, ask your doctor's office what they're seeing, and get the answer in writing when you can.

What can I do if prior authorization is denied? Appeal. Start with your plan's internal appeal, then external review if needed. See denied claims: how to appeal in Tennessee.

Do I need prior authorization for emergency care? No. Get emergency care first; authorization requirements don't apply to emergencies.

Keep reading

• Denied claims: how to appeal in Tennessee
• Provider networks: HMO, PPO, EPO
• What you'll pay: costs explained
• How we verify our information
• Glossary

Sources

• HealthCare.gov — prior authorization and referral explanations
• Your plan's evidence of coverage (the definitive source for what your specific plan requires)

Every figure and claim on this site is checked against primary sources. See how we verify.