What Is Prior Authorization and Why Does My Child Need It?

If you've ever picked up a prescription at the pharmacy and been told it's “on hold because we're waiting on prior auth,” or gotten a call from your child's doctor's office saying a procedure is “pending insurance approval,” you've already run into prior authorization without anyone explaining what it actually is.

I'm Jen, a pediatric LPN with 29 years of experience, and I want to give you a straightforward answer. Prior authorization is a formal approval process your insurance company uses before they will pay for certain types of care. Your child's doctor recommends something — a medication, a test, a specialist, a therapy — and before that care can happen, the doctor's office has to submit clinical information to your insurance company and wait for them to say yes. Until they say yes, the insurance company will not pay for it, and most pharmacies, imaging centers, and specialists will not move forward with the service.

Why your child specifically might need one:

Not every pediatric service requires prior authorization. The system targets specific categories. Brand-name and specialty medications are a big one — anything from a brand-name ADHD stimulant to a biologic injection for severe asthma to a growth hormone prescription almost always requires prior auth. Advanced imaging is another — MRIs, CT scans, sleep studies, echocardiograms. Many therapies require it — physical therapy, occupational therapy, speech therapy, applied behavior analysis for autism. Specialist referrals often require it depending on your plan. Durable medical equipment like nebulizers, CPAP machines, and feeding pumps almost always requires it. And surgeries — even outpatient procedures like ear tubes — usually require it. If your child has a chronic condition like asthma, ADHD, autism, type 1 diabetes, a feeding disorder, a seizure disorder, or any complex medical need, you are going to be running into prior authorization regularly. Probably more often than you'd like.

Why the insurance company gets to require this:

When you signed up for your insurance plan, the policy document included terms that allow the insurance company to require prior authorization for certain services. They use it as a tool to manage costs and to enforce their own clinical guidelines. From their perspective, requiring prior approval gives them a chance to review whether the recommended care matches their criteria for medical necessity before they commit to paying for it.

You may strongly disagree with their criteria. That's a separate fight, and a legitimate one. But the legal authority to require prior authorization is built into your policy.

What this means for you practically:

The most important thing to know is that prior authorization is not a denial — it's a process step. Your child's doctor recommends something. The insurance company reviews it. They either approve it or deny it. If they approve it, your child gets the care and the insurance company pays per your plan's terms. If they deny it, you have appeal rights, and I'll cover those in detail in another post in this series.

The second most important thing to know is that you can advocate inside this process. You can call the insurance company. You can ask the doctor's office for status updates. You can request escalation if the timeline is hurting your child. You are not stuck waiting passively.

Who actually reviews these requests:

It helps to know what's happening on the other end. When the doctor's office submits your child's prior authorization, the request lands at the insurance company in front of a clinical review team. The first reader is usually a nurse or pharmacist following a checklist of criteria for that specific drug, procedure, or service. If the submission checks every box, it's approved at that level. If anything is missing or ambiguous, the request goes to a physician medical director for a closer look or gets sent back to the doctor's office with a request for more information.

The physician medical director on the insurance side is rarely a pediatric specialist. They are usually a general physician applying carrier criteria written for the broad population. This is one reason pediatric requests get extra scrutiny — the reviewer may not be familiar with the specific medical considerations of treating children, and your doctor's office may need to advocate explicitly for why pediatric care looks different than adult care.

What to expect at the pharmacy or imaging center:

When a prior authorization is in process, the practical experience for you usually looks like one of three things. At the pharmacy, the technician tells you the prescription “needs prior authorization” and they can't fill it. The pharmacy faxes a notification to the doctor's office and the prior auth process begins. You typically leave without the medication and wait for someone to call when it's approved.

At the imaging center, you may not be able to schedule the study until prior authorization is on file. At the specialist's office, the appointment may stay on the calendar but the specific service requested during the visit may not move forward until approval is in hand.

If your child's pediatric practice is struggling to keep up with prior authorization volume, that's actually a sign of a larger industry problem. Most small practices don't have dedicated authorization staff, and that gap is exactly what Precision Pediatric Operations was built to fill. We handle authorization management for pediatric practices so that requests like the one for your child move quickly and accurately through the system.

If you have a specific situation you're navigating right now, the other posts in this series go deeper on what to do next.