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Prior Authorization

Meaning

Prior Authorization (PA) is a cost-control administrative process utilized by health insurance companies in which a healthcare provider must obtain explicit approval before a patient can receive coverage for a specific prescription, procedure, or medical service. This requirement is particularly common for high-cost medications, non-formulary drugs, and specialized treatments, including many advanced hormonal therapies and diagnostic tests. The process often involves submitting detailed clinical documentation to demonstrate that the requested treatment meets the insurer’s criteria for medical necessity. Navigating the complexities of prior authorization is a significant administrative burden in clinical practice, frequently delaying patient access to essential care.