Prior authorization (sometimes called pre approval or advanced approval) means your health insurance provider reviews certain tests, treatments or medications before they’re given.
This review helps make sure:
- The care is medically appropriate
- It follows evidence based guidelines
- There aren’t safer or lower cost options that work just as well
Your request is reviewed by doctors, nurses and other clinically qualified experts.
Please know:
- Prior authorization is not meant to delay or deny care
- Our goal is to support you, not create barriers
- Help is always available, and you have options
Prior authorization is used to:
- Protect your health (for example, avoiding unnecessary radiation from repeat imaging)
- Avoid surprise costs when a service might not be covered
- Ensure every healthcare dollar is spent wisely—for you, employers and the healthcare system
Most care does not require prior authorization. We will never require prior authorization for:
- Emergency room services
- Ambulance services
- Urgent care
- Primary care visits
- Preventive care (like covered screenings and immunizations)
- Specialist and other practitioner office visits
- Diagnostic tests
If you need emergency help, get care right away—approval is not required
Your provider recommends a service that may require prior authorization based on your health plan. Your provider will then submit a request and supporting medical information on your behalf.
Your provider sends the request
They explain why the service is needed.
Clinical experts review it
Doctors and nurses review the information—most reviews happen quickly.
You receive a decision
We’ll send you a letter letting you know if the service is approved or not. You can also see the status in Blueprint Portal. Your provider will be notified, too.
What you can do now
- Talk with your provider about your care and any questions you have
- Wait for your approval letter before scheduling the service
- Call us if you want to check the status or need help understanding your options
If a service isn’t approved, you still have options. You can:
- Discuss other treatment choices with your provider
- Ask about different care settings
- File an appeal if you disagree with the decision
If a service is approved:
- The service is covered
- You pay your normal cost share (copay, coinsurance, or deductible)
- The service must be done at the approved location, if one is listed
If a service is not approved:
- The service may not be covered
- You could be responsible for the full cost
You’ll receive clear information on:
- Why it wasn’t approved
- What your next steps are
- How to appeal the decision
Need help or have questions?
Call the number on the back of your member ID card and we can help you:
- Check the status of a request
- Understand your benefits
- Talk through next steps
You can also sign in to Blueprint Portal to see more details about your prior authorization paperwork or denied prior authorizations. If your provider has questions, they can contact us directly.