Know the approval process. Know what your policy pays.

What is prior authorization?

Also called preauthorization, prior approval, or precertification, it is a health plan’s review before certain services, equipment, or prescriptions are covered. The provider generally submits the clinical information needed for the plan to assess the request against its coverage and medical-necessity rules.

A doctor ordering care does not automatically satisfy a plan’s authorization requirement. Approval also does not guarantee that every charge will be paid: eligibility, benefits, network rules, and cost sharing still apply.

A practical sequence for planned care

1. Ask the provider and plan whether authorization is needed, who will submit it, and whether all clinicians and facilities are in network.
2. Confirm the request was submitted with the necessary clinical records. A missing-information request is different from a final denial.
3. Obtain the decision in writing. Check the approved service, facility, number of visits or days, and dates. Keep the authorization number.
4. Ask for an estimate of your deductible, copayment, and coinsurance separately from the authorization.
5. If denied, request the reason and relevant criteria. Ask the clinician about missing records, a corrected request, or an appeal. Follow the notice’s deadlines; request expedited review when medically appropriate.

Original Medicare usually does not require prior authorization, although some services do. Medicare Advantage and other health plans may require it for specified care. Rules vary by coverage and service. Do not delay emergency care to seek routine prior approval; emergency-service protections and later notification rules differ from planned care.

• Medicare: compare coverage rules ↗
• Medicare: appeal a coverage decision ↗

How could it help with a daily hospital copayment?

Some Medicare Advantage plans charge a daily inpatient copayment for a specified number of days. A qualifying indemnity daily benefit can offset part or all of that amount if the covered event and days meet its rules.

For a hypothetical example—not a quote—five eligible days with a $300 daily plan copayment total $1,500. An indemnity contract paying $200 for each of those same five covered days would provide $1,000, leaving a $500 difference before other expenses and premiums. Actual benefit days may not match the health plan’s billed days.

Original Medicare has a different structure: its Part A hospital deductible is charged per benefit period, with daily coinsurance for longer stays. Do not assume everyone has a daily hospital copayment from day one.

Observation can affect this benefit too.

A policy requiring inpatient confinement may not pay an admission or daily benefit for outpatient observation. Some contracts have a separate observation benefit with its own conditions. Read the definition before buying, and ask how an observation-only stay would be treated.

Learn about inpatient status, observation, and skilled nursing →

Questions worth asking before adding a premium

• What gaps remain after my existing health and supplemental coverage?
• Would an admission, an observation stay, or both qualify?
• Is payment per admission, per day, or both, and for how many days?
• Are benefits reduced by age, subject to waiting periods, or limited for an existing condition?
• Can I sustain this premium, and is there a more useful priority for my budget?

Examples are arithmetic illustrations, not actual plan benefits or policy offers. Availability and eligibility vary. General education does not replace either contract. Reviewed October 2026.