About PriorIntel

Prior authorization (or prior approval) is a process where your insurance company reviews your upcoming medical procedure before you receive it. The insurer verifies that your treatment meets their coverage criteria and is medically necessary for your condition. If approved, they authorize payment. If denied, you can appeal.

CPT (Current Procedural Terminology) codes are five-character codes that describe specific medical procedures, tests, and services. For example, 30520 is a rhinoplasty code, and 99213 is an office visit code. Insurance companies use CPT codes to determine coverage and pricing. HCPCS codes are similar but used for supplies and services.

No. PriorIntel is educational only and not medical, legal, or financial advice. We provide information about insurance procedures and appeal strategies. Always verify information with your healthcare provider, insurance company, and legal counsel. Individual coverage depends on your specific plan, clinical situation, and insurer.

Most states require a two-step process: (1) Internal Appeal — submit your denial notice, additional medical evidence, and a written explanation to your insurer within the required deadline, typically 30-60 days. (2) External Review — if denied internally, request an independent review by a physician who was not involved in the initial decision. Use our Appeal Letter Generator to create a compelling submission.

PriorIntel was created by a team of healthcare policy advocates, designers, and engineers frustrated by the prior authorization crisis. We built this tool to give patients the same access to coverage information that insurers have — so they can prepare, appeal, and win.

Yes. PriorIntel never collects personal health information. Our report form uses only dropdown selections — no free text that could contain names, IDs, or identifiers. All reports are completely anonymous and aggregated. We don't track individual users or sell data.

An external review is an independent evaluation of your insurance denial by a third-party physician who was not involved in the original decision. Under the ACA, you have the right to request an external review after exhausting your insurer’s internal appeals process. The external reviewer’s decision is binding on the insurer. Contact your state Department of Insurance or check our state-by-state appeal rights page for specific instructions.

Medical necessity means that a treatment, test, or procedure is clinically appropriate and required for diagnosing or treating your condition based on accepted medical standards. Insurers use medical necessity criteria to decide whether to cover a procedure. Denials for lack of medical necessity are the most common type, but they can often be overturned with proper documentation from your physician.

Timelines vary by insurer and state, but most plans require you to file an internal appeal within 180 days of receiving the denial notice. For urgent or pre-service denials, insurers must respond within 72 hours for expedited appeals and 30 days for standard pre-service appeals. Always check the specific deadline printed on your denial letter and act quickly.

Step therapy (also called fail-first) is when your insurer requires you to try less expensive treatments before approving the one your doctor originally prescribed. For example, trying physical therapy before approving an MRI, or trying generic medications before a brand-name drug. You can request a step therapy exception from your insurer if your doctor documents why the required steps are not appropriate for your condition.

Yes. Our database includes procedures commonly subject to prior authorization under Medicare Advantage plans and Medicaid managed care. Traditional (Original) Medicare has more limited prior auth requirements, but Medicare Advantage plans operated by private insurers apply their own prior auth rules. We cover both commercial and government plan requirements.

A peer-to-peer review is a phone call between your treating physician and the insurance company’s medical director to discuss a denied authorization. This is one of the most effective ways to overturn a denial because it allows your doctor to explain the clinical rationale directly. Ask your doctor’s office to request a peer-to-peer review as soon as a denial is received.

Yes. If you have employer-sponsored insurance, your HR department or benefits administrator can advocate on your behalf with the insurer. Employers are the insurer’s actual customer and often have more leverage than individual patients. Some employers also offer patient advocacy services or employee assistance programs that can help navigate the appeals process.