Prior authorization — also called prior auth, PA, or precertification — is one of the most frustrating parts of using health insurance. Your doctor says you need a procedure or medication, but your insurance company says "not so fast" and wants to review it first. Done well, it's a reasonable cost-control measure. Done badly, it's a wall between you and the care you need.
Understanding how prior authorization actually works in Florida — including your rights when it's denied — puts you in a much stronger position to navigate it.
What Services Typically Require Prior Authorization
Not every service requires PA — routine office visits and most primary care services do not. The list varies by plan, but common categories that typically require prior authorization include:
- Specialty medications and brand-name drugs (especially biologics)
- Elective surgeries and outpatient procedures
- Planned hospital admissions
- Advanced imaging: MRI, CT scans, PET scans
- Durable medical equipment (wheelchairs, CPAP machines, etc.)
- Certain mental health and substance use treatment programs
- Physical therapy beyond a set number of visits
- Home health care and skilled nursing facility stays
Your plan's Summary of Benefits and Coverage (SBC) lists which services require PA. Your doctor's office — especially a specialist — will usually know your plan's PA requirements and handle the request on your behalf.
How to Request Prior Authorization
In almost all cases, your doctor or their office submits the PA request — not you. Here's how the process typically flows:
- Your doctor determines you need a specific service or medication
- The office submits a PA request to your insurer with clinical documentation supporting the need
- The insurer's medical reviewers evaluate the request against clinical criteria
- The insurer approves, denies, or requests more information within the required timeframe
Even though your doctor submits the PA, you can help by confirming your insurance information is current with the office, making sure your insurer has your correct plan ID, and following up if you haven't heard back within the expected timeframe. Delays are often administrative, not clinical.
Prior Authorization Timelines in Florida
| Request Type | Insurer Must Respond Within |
|---|---|
| Standard PA request (non-urgent) | 5 business days (Florida) |
| Expedited PA request (urgent care) | 72 hours |
| Concurrent review (ongoing hospitalization) | 1 business day |
| Emergency care | PA not required — retroactive review only |
What to Do When Prior Authorization Is Denied
A PA denial is not the end. It triggers a formal process with defined steps and timelines that protect your rights.
Step 1: Understand the Denial Reason
The insurer must send a written denial explaining the specific clinical criteria the request failed to meet. Read this carefully — the reason shapes your response.
Step 2: Request a Peer-to-Peer Review
This is often the fastest path to a reversal. A peer-to-peer review is a direct phone call between your doctor and the insurance company's medical reviewer — a physician to physician conversation. Ask your doctor's office to request a peer-to-peer review immediately after a denial.
Many PA denials are reversed at the peer-to-peer stage without ever reaching formal appeal. The insurer's reviewer may have based the denial on incomplete information, and a direct clinical conversation often resolves it quickly.
Step 3: File a Formal Appeal
If the peer-to-peer doesn't resolve it, you have the right to appeal. The same appeal process that applies to claim denials applies to PA denials — internal appeal first, then external review through an IRO if needed. See our guide on how to appeal a health insurance denial in Florida for the full process.
If you receive a service that required PA before it was approved (or appealed), your insurer may deny the claim entirely — even if the service was medically appropriate. Wait for a final decision or work with your doctor on an alternative if care is urgent but not an emergency.
Florida's Gold Carding Rule: Bypassing PA Entirely
Florida enacted a Gold Carding law that is a significant consumer and physician protection. Under this rule, if a doctor has a 90% or higher PA approval rate for a specific service over the prior 12 months, the insurer must exempt that doctor from requiring PA for that service.
In practice, this means:
- Your doctor may already be Gold Carded with your insurer for certain services
- If Gold Carded, they can order those services without submitting a PA request
- You can ask your doctor whether they have Gold Card status with your specific insurer
Florida's Gold Carding law is one of the strongest in the country and applies to most state-regulated commercial plans. Self-funded ERISA plans may not be subject to this rule.
Choosing a plan with a network of doctors who know your insurer's PA requirements — and ideally are Gold Carded for common services — can save you significant delays. Use Florida Plan Finder to compare plans and networks, or talk to a licensed broker at Get Florida Coverage to find plans with more streamlined PA processes for your specific conditions.