The Difference Between Prior Auth and Precertification

You know that moment when a new team member asks you to explain the difference between prior authorization and precertification, and you pause for a second? Yeah, me too. These terms get thrown around interchangeably in our day-to-day work, and honestly, it's easy to see why there's confusion. While they're related processes that both involve getting approval from insurance companies before providing care, they're not exactly the same thing – and understanding the distinction can actually make your life easier when you're dealing with payers and training staff.

Let me walk you through what I've learned over the years about these two processes, because getting this right upfront can save you hours of back-and-forth with insurance companies later.

The Core Differences: What You Need to Know

Here's the thing that took me way too long to fully grasp: precertification is actually a type of prior authorization, but not all prior auths are precertifications. Think of prior authorization as the umbrella term, and precertification as one specific approach underneath it.

Prior authorization is the broad process where insurance companies require approval before they'll cover certain treatments, procedures, medications, or services. It's their way of controlling costs and making sure the proposed treatment meets their medical necessity criteria.

Precertification, on the other hand, is typically used for scheduled procedures and treatments – stuff you can plan ahead for. Think elective surgeries, MRIs, specialized equipment, or certain high-cost medications. The insurance company wants to review the case beforehand to confirm it meets their coverage requirements.

The key difference I always tell my team: if you're scheduling something in advance and need approval, you're probably dealing with precertification. If you're trying to get approval for something that could be more immediate or urgent, or for ongoing treatment plans, you're likely in prior auth territory.

When Each Process Kicks In

Precertification scenarios usually involve:

• Elective surgeries (knee replacements, cosmetic procedures with medical necessity)


• Advanced imaging like MRIs or CT scans


• Durable medical equipment


• Some specialty medications


• Planned hospital admissions

I remember working with a patient who needed a knee replacement. We knew about it months in advance, had all the documentation ready, and could work through the precertification process methodically. That's the ideal scenario – you've got time to gather everything the insurance company wants to see.

Prior authorization covers a broader range, including:

• Specialty medications that need ongoing approval


• Emergency procedures (retrospective review)


• Referrals to specialists


• Certain diagnostic tests


• Step therapy requirements

Here's a real example that happens all the time: a patient comes in with severe back pain, and you want to refer them to a pain management specialist. The insurance company requires prior auth for that referral. It's not precertification because it's not a specific procedure you're scheduling – it's approval for a type of care.

The Timeline Game: Planning Your Approach

This is where understanding the difference really pays off in practical terms. Precertification typically has longer processing times because everyone involved knows it's planned care. You might be looking at 5-15 business days, sometimes longer for complex cases.

Prior authorizations can vary wildly. Some are processed within 24-48 hours, especially for urgent situations. Others might take just as long as precertifications, particularly for specialty drugs or complex treatments.

Here's what I've learned works best:

For precertifications:

• Start the process as soon as the procedure is scheduled


• Front-load all your documentation – don't wait for them to ask


• Build in extra time for potential back-and-forth


• Set up tracking systems so nothing falls through the cracks

For prior auths:

• Understand your common payers' turnaround times


• Know which situations qualify for expedited review


• Keep templates ready for frequently requested procedures


• Have a clear escalation process for urgent cases

Documentation: Your Best Friend (Or Biggest Headache)

Both processes live and die by documentation, but they often require different approaches. Precertification requests usually need comprehensive upfront documentation because reviewers have time to thoroughly evaluate the case.

For prior auths, especially urgent ones, you might start with essential documentation and provide additional details as requested. The key is knowing what each payer typically wants to see for common scenarios.

I always tell my billing team: create checklists for your most common requests. If you're constantly dealing with precertification for MRIs, you should have a standardized list of what documentation to include. Same goes for prior auths for specialty referrals or medications.

And here's something that's becoming more common – AI-powered tools that can help generate appeals or organize documentation for these requests. While I'm not saying they replace good clinical judgment, they can definitely help streamline the paperwork side of things.

Making It Work in the Real World

The biggest practical tip I can share? Train your staff to ask the right questions upfront. When a provider orders something that might need approval, the first question should be: "Is this something we can schedule in advance, or does it need to happen soon?" That simple question helps determine whether you're dealing with precertification or standard prior auth.

Also, don't assume the insurance company uses these terms the same way you do. I've seen payers use "prior authorization" for everything, even when they clearly mean precertification. When in doubt, ask them directly about their process and timeline expectations.

Moving Forward: Set Your Team Up for Success

Look, at the end of the day, whether you call it prior auth or precertification, you're still dealing with insurance company approval processes that can make or break your revenue cycle. The terminology matters less than having solid systems in place.

Focus on building workflows that account for different timeline requirements, training staff to gather the right documentation upfront, and maintaining good relationships with your payer reps who can help clarify their specific processes. And remember – every insurance company does things slightly differently, so what works with one might not work with another.

The goal isn't to become a terminology expert; it's to get your patients the care they need while getting paid for the work you do. Understanding these distinctions just helps you navigate the system more effectively.