February 22, 2025

Insurance Authorizations

John Dang M.D.

Authorizations are sometimes necessary for more expensive procedures, tests, medications.  Historically, insurance authorizations are a feature of HMO plans, but not PPO plans.

In practice, nowadays, insurance authorizations are sometimes necessary even for PPO plans. The following scenarios are for patients with PPO plans:
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1. Specialists – no authorizations necessary.
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2. Medications – mostly no authorizations. Some specialty drugs (diabetes, rheumatologic, cancer, etc) would require prior authorization; this is done by the prescribing physician.
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3. Imaging – authorization may be necessary for MRI, PET studies, etc. This would be done by the imaging center.
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4. Elective procedures – authorization done by the surgeon.

For HMO patients, authorizations are necessary for:
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1. Specialists – authorization for first visit done by primary care physician (PCP); thereafter, the specialist will authorize their own visits, if within 3 years.
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2. Medications – prior authorizations necessary for certain medications, similar to PPO plans. This is done by the prescribing physician.
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3. Imaging – authorizations necessary for any imaging other than X-rays; this is done by the ordering physician.
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4. Elective procedures – authorization done by the surgeon.