When a claim comes back denied because prior authorization wasn’t obtained, it can be frustrating — especially when you already verified the patient’s coverage. But insurance verification and prior authorization are two entirely different processes — and confusing them can lead to denied claims and lost revenue.
What is insurance verification?
Insurance verification is the process of contacting a patient’s insurance company to confirm the coverage available for treatment. It goes well beyond simply confirming coverage is valid on the date of service. Key items confirmed during verification include:
- Validity of the patient’s coverage
- Deductibles and whether they have been met
- Annual maximums and how much has been used
- Frequency limits, age limits, and alternative benefit downgrades for specific treatments
- Whether specific treatments are covered and at what percentage
- Whether pre-authorization is required for any planned treatment
- Whether the plan has a waiting period
Due to HIPAA requirements, insurance companies can only verify coverage when all identifying information matches exactly — any discrepancy in a patient’s name, date of birth, ID number, or address can prevent verification entirely. Insurance verification can take up a significant portion of the workday, including lengthy hold times with some carriers.
What is prior authorization?
Prior authorization is the process of obtaining a payor’s written approval for a planned treatment before it begins. It is separate from — and in addition to — insurance verification. Even when a patient’s coverage has been verified, certain treatments still require the payor to pre-approve them before they will pay the claim.
Prior authorization typically requires submitting a proposed treatment plan to the insurance carrier and receiving a written response detailing which treatments are approved and which are not.
If a plan requires prior authorization, failing to obtain it before treatment begins will result in a denied claim.
Insurance Verification vs Prior Authorization: Key Differences
| Insurance Verification | Prior Authorization | |
|---|---|---|
| Purpose | Confirms coverage details and benefits before treatment | Obtains payor approval for a specific treatment before it begins |
| Timing | Before the appointment, during pre-appointment readiness | Before treatment begins — must be completed before the appointment |
| Required for all patients | Always recommended | Only when the plan requires it |
| If not completed | Claims are more likely to be denied or delayed | Claim will be denied with little to no chance of appeal |
Is insurance verification required?
Technically, a claim can be submitted without first verifying insurance coverage — but the chance of it being paid is significantly reduced. Verification confirms that everything is in order before treatment begins, greatly improving the likelihood that the claim will be paid with minimal issues. When verification is omitted, claims are more likely to be denied, and patients are more likely to receive unexpected balances.
Is prior authorization required?
When prior authorization is required by the plan, it is the only way to guarantee that a claim will be paid. Without it, the claim will be denied except in rare emergency circumstances — such as after-hours or weekend treatment where obtaining authorization in advance was not possible. Even then, payment is not guaranteed.
What treatment requires pre-authorization varies by plan. HMO plans often require pre-authorization for specialty treatment such as endodontics or oral surgery. Medicare Advantage and active duty military plans tend to require pre-authorization for most treatment beyond basic services like exams and x-rays. Always confirm with the carrier during the verification process whether pre-authorization is required.
What is needed for insurance verification?
The two most critical requirements for insurance verification are time and accurate patient information.
Verification can be a lengthy process — some carriers have hold times of over an hour. And because of HIPAA requirements, any discrepancy in patient information will prevent the carrier from providing verification. Before contacting the carrier, confirm the following is correct:
- Patient’s full name and date of birth
- Insurance group number and insurance ID
- Subscriber name and date of birth (if different from the patient)
- Home address
For more on what to collect before verifying, see our guide: Pre-Appointment Readiness: How to Prepare for Every Patient Visit.
What is needed for prior authorization?
Most prior authorization requires submitting a request to the insurance carrier that includes the proposed treatment plan. Many carriers have specific forms that must be completed. The carrier will respond with a written authorization form detailing which treatments are approved.
It is critical that this process be completed before any treatment begins. There is generally no opportunity to backdate authorization once treatment is completed.
Frequently Asked Questions
Technically yes, but it significantly reduces the chance of the claim being paid. Verification confirms coverage is valid, identifies plan limitations, and flags whether pre-authorization is required — all of which are essential for clean claim submission.
If the plan requires prior authorization and it was not obtained, the claim will be denied. In most cases there is no opportunity to obtain authorization after treatment has been completed, and appeals are rarely successful without it. The only exception is emergency treatment performed when authorization was genuinely impossible to obtain in advance.
It depends on the patient’s plan. HMO plans frequently require pre-authorization for specialty treatment. Medicare Advantage and active duty military plans often require it for most treatment beyond basic services. Always ask the carrier during the verification process whether any planned treatment requires pre-authorization.
It varies by carrier. Some verifications can be completed quickly through online portals, while others require a phone call with hold times that can exceed an hour. Because of the time involved, many practices choose to outsource verification to a dedicated team. For more information, see our guide: Dental Insurance Verification Outsourcing: A Complete Guide.
Need Help With Insurance Verification?
Insurance verification and prior authorization are both time-consuming processes that require close attention to detail. If your team is struggling to keep up, consider outsourcing insurance verification to eAssist. Our dental insurance verification professionals work to get your benefits confirmed accurately before every appointment. To learn more, schedule a free consultation.
