PA Check — Prior Authorization Lookup
for Any CPT Code & Any Insurer
The most complete free PA lookup tool for doctors. 500+ CPT codes · 30+ insurance companies · 25 specialties — including Florida Blue, Premera, Regence, CareSource, Independence Blue Cross, Ambetter, UPMC, Geisinger & more.
PA Check — Prior Authorization Lookup
Frequently asked questions
Which insurance companies require prior authorization?
All major US commercial payers require PA for certain services. Anthem/Elevance and UHC have the broadest PA requirements. As of 2026, over 30 insurers — including Florida Blue, Premera, Regence, CareSource, Independence Blue Cross, and Ambetter — require PA for surgical procedures, advanced imaging, behavioral health, and specialty drugs.
Does Florida Blue require prior authorization?
Yes. Florida Blue (GuideWell) requires PA for advanced imaging (MRI/CT/PET via Evolent), surgical procedures, orthopedic surgery, behavioral health admissions, home health, DME, specialty drugs, and bariatric surgery. Florida Blue uses Evolent for radiology PA and Availity for general authorizations.
Does Premera require prior authorization?
Yes. Premera Blue Cross requires PA for inpatient admissions, surgical procedures, advanced imaging, behavioral health, home health, DME, and specialty drugs. Premera uses Carelon (formerly AIM) for cardiovascular, radiology, and sleep medicine PA programs.
Does Regence require prior authorization?
Yes. Regence uses Carelon for cardiac, radiology, and sleep medicine PA. Regence requires PA for advanced imaging, surgical procedures, inpatient admissions, DME, home health, and specialty drugs. Submit via Availity portal. PA requirements are updated monthly.
Does CareSource require prior authorization?
Yes. CareSource (Medicaid/Marketplace) requires PA for inpatient admissions, surgeries, advanced imaging, behavioral health, home health, DME, and specialty medications. CareSource operates in OH, GA, IN, KY, WV, MO, and NC. Submit via Availity or CareSource provider portal.
Does Independence Blue Cross require prior authorization?
Yes. Independence Blue Cross (Philadelphia area) requires PA for inpatient admissions, surgical procedures, advanced imaging, behavioral health services, specialty drugs, home health, and DME. Uses AIM Specialty Health for imaging and musculoskeletal PA programs.
Does TRICARE require prior authorization?
Yes. TRICARE requires PA for non-emergency inpatient admissions, specialty care in TRICARE Prime, certain surgical procedures, home health, and some DME. TRICARE Prime members need referrals; TRICARE Select allows direct specialist access for most care. Submit PA via Evicore or the TRICARE portal.
New 2026 PA rule: What changed?
Starting January 2026, major payers committed to: (1) honoring existing PA for 90 days when a patient switches plans, (2) providing clearer denial reasons, (3) ensuring medical professionals review all medical denials, and (4) targeting 80% real-time electronic PA decisions by 2027. This applies to UHC, Aetna, Cigna, Humana, Elevance, and BCBS plans.
Prior Authorization in 2026: The Complete Guide Physicians Actually Need
If you have ever watched a medically necessary procedure get delayed — or denied outright — because of a prior authorization bottleneck, this guide was written for you. It consolidates the most current payer-specific PA requirements, the real impact of 2026 rule changes, approval strategies that work in practice, and tools that save your staff hours every week.
Starting January 2026, major payers — UHC, Aetna, Cigna, Humana, Elevance, and BCBS plans — committed to honoring existing prior authorizations for 90 days when patients switch plans, ensuring physicians review all medical denials, and targeting 80% real-time electronic PA decisions by 2027. Despite these reforms, over 35 million PA requests are submitted annually in the US, with denial rates ranging from 2% to over 35% depending on the payer and specialty.
What Is Prior Authorization? (And Why It Matters More in 2026)
Prior authorization — also called “prior auth,” “PA,” “pre-authorization,” or “pre-certification” — is a requirement from health insurers that providers obtain payer approval before delivering certain medical services, procedures, or medications. It is the insurer’s mechanism to confirm a proposed service meets their coverage criteria before they commit to paying for it.
Whether a CPT code requires PA depends on three variables: the insurance company, the patient’s specific plan, and the place of service. CPT 27447 (total knee arthroplasty) requires PA from Anthem at every facility type but not from traditional Medicare FFS in any setting. The same MRI brain scan (CPT 70553) requires PA from UHC commercial plans and most Medicare Advantage plans — but not traditional Medicare.
What is the difference between prior authorization and a referral?
A referral directs the patient to a specialist — it’s about routing care. A prior authorization is the insurer’s approval for a specific procedure — it’s about payment. You can have a referral without PA and often need PA without a referral. They are entirely separate administrative requirements and are commonly confused by patients and even some staff.
Physicians and their staff spend an average of 13 hours per week completing PA requests — more than one full workday every week. For a four-physician practice, that exceeds 2,700 staff hours annually absorbed by administrative overhead rather than patient care.
The True Cost of Prior Authorization — Beyond the Paperwork
The administrative cost of PA is well-documented, but the clinical cost is what keeps physicians up at night. A 2024 survey by the Kaiser Family Foundation found that 40% of physicians reported a patient experienced a serious adverse event — including hospitalization or permanent disability — because a PA delay prevented timely care. These are not edge cases. They represent a systemic failure happening across every specialty in every state.
For surgical specialties, the burden hits hardest. Orthopedic surgeons booking total joint replacements, spine surgeons scheduling lumbar fusions, and cardiac surgeons booking TAVR procedures all face PA timelines that can stretch 10 to 21 days — with denial rates as high as 37% from the most restrictive payers. Every denial that goes unappealed costs the practice roughly $94 in administrative overhead and costs the patient real time.
How to Use the PA Check Tool — Step-by-Step
The PA Check tool at the top of this page gives physicians, medical assistants, and billing staff instant prior authorization guidance for any CPT or HCPCS code across 30+ major US insurers — in under one second, with no login required.
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1Enter the CPT or HCPCS Code Type the exact procedure code: CPT codes (5-digit numeric), HCPCS Level II (letter + 4 digits), or Category III codes. Examples:
27447(total knee arthroplasty),70553(MRI brain w/ and w/o contrast),J0129(Abatacept/Orencia),E0601(CPAP device). -
2Select the Insurance Company For Medicare Advantage patients, always select “Medicare Advantage” — not “Medicare (Traditional FFS)” — because MA plans have entirely different PA requirements. Check the patient’s card: if a private insurer logo appears alongside Medicare, that’s Medicare Advantage.
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3Select a Specialty (Strongly Recommended) Selecting a specialty displays quick-access CPT chips for that discipline and improves PA data accuracy. Use the chips to check multiple codes in seconds without retyping.
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4Select Place of Service Critical for Medicare. PA requirements differ between outpatient hospital (POS 22), ASC (POS 24), and office (POS 11). The Medicare CMS OPD PA program requires PA for specific procedures only in the outpatient hospital setting — the same procedure in an ASC does not trigger the PA requirement.
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5Review Results and Act Results show PA status, turnaround time, approval rate, submitting vendor, and documentation tips for that specialty-payer combination. Always verify directly with the payer before scheduling — PA requirements change monthly at some payers.
Prior Authorization Requirements by Specialty — 2026 Edition
Different specialties face dramatically different PA burdens. Understanding payer requirements for your specialty — and the documentation triggers that drive approvals versus denials — is the foundation of efficient PA management.
Orthopedics & Spine Surgery
Orthopedic and spine surgery carry the highest PA burden of any specialty. For total joint replacement (CPT 27447, 27130) and spinal fusion (CPT 22612, 22551), virtually every commercial payer requires PA. Approval rates range from 63% (Anthem/spine) to 76% (Humana/orthopedics). The single most common denial reason — across every payer — is insufficient conservative care documentation. Payers want 3 months of documented conservative care for joint replacement and 6 months for spinal fusion, with specific therapy, injection, and medication records. Including functional outcome scores — KOOS/WOMAC for knee, HOOS for hip, Oswestry for spine — directly addresses payer criteria and measurably improves approval rates.
Radiology & Advanced Imaging
MRI, CT, and PET/CT require PA from virtually all commercial payers and most Medicare Advantage plans. Traditional Medicare FFS does NOT require PA for imaging. Most commercial payers route imaging PA through Evicore, Carelon (formerly AIM), or Evolent/RadMD. Turnaround is typically 1–3 days with portal submission, making imaging one of the faster PA categories. UHC’s AIM portal, Aetna’s Evicore portal, and Regence/Premera’s Carelon portal all support real-time or same-day decisions for well-documented cases.
Cardiology & Cardiac Devices
In a 2025 policy change, United Healthcare eliminated PA for echocardiography and nuclear cardiology imaging on commercial plans — a significant reduction for cardiologists. TAVR (CPT 33361), CABG (CPT 33533–33536), PCI (CPT 92920–92944), and all cardiac device implantation — pacemakers, ICDs, S-ICDs, CardioMEMS, LINQ — continue to require PA from all major payers. Average approval rates for cardiac procedures run 79–85%, higher than surgical specialties due to the strong objective clinical documentation available.
Behavioral Health & Psychiatry
The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that behavioral health PA standards be no more restrictive than medical/surgical standards — but enforcement remains inconsistent. TMS (CPT 90867–90869), ABA therapy (CPT 97151–97157), ECT (CPT 90870), partial hospitalization, and residential treatment consistently require PA. Routine outpatient psychotherapy typically does not, but ongoing session counts trigger concurrent review at most commercial payers at 8–12 sessions.
Oncology & CAR-T Cell Therapy
Chemotherapy infusion (CPT 96413, 96415), radiation therapy (IMRT: CPT 77385–77386, SBRT: CPT 77373), and all systemic oncology drugs require PA from every major payer. CAR-T cell therapies (CPT 0537T–0540T, Q2055) require PA with 10–21 day review periods handled by dedicated payer transplant or specialty pharmacy programs. Staging PET/CT (CPT 78816) requires PA from commercial payers but not traditional Medicare.
| Specialty | PA Required? | Avg. Turnaround | Avg. Approval Rate | Denial Risk | Conservative Care? |
|---|---|---|---|---|---|
| Spine Surgery | Yes — Always | 10–15 days | 63–70% | Very High | Yes — 6+ months |
| Orthopedics | Yes — Always | 5–10 days | 70–76% | High | Yes — 3+ months |
| Transplant & CAR-T | Yes — Always | 10–21 days | 65–80% | High | N/A |
| Wound Care / Skin Substitutes | Yes — Always | 2–5 days | 71–77% | High | Yes |
| Rheumatology Biologics | Yes — Always | 3–5 days | 70–82% | High | Yes — DMARD failure |
| Cardiac Devices & EP | Yes — Always | 3–5 days | 79–82% | Moderate | No |
| Radiology — MRI/CT/PET | Yes — Always | 1–3 days | 81–87% | Low | No |
| Pain Management | Yes — Always | 2–5 days | 79–83% | Moderate | Yes |
| Oncology | Yes — Always | 2–5 days | 84–87% | Moderate | No |
| Gastroenterology | Conditional | 1–3 days | 85–90% | Low | No |
| PT / Occupational Therapy | Varies by plan | 1–2 days | 88–91% | Low | No |
| Primary Care / Preventive | No | N/A | N/A | None | No |
Data represents typical commercial plan requirements. Individual plan requirements vary. Verify with the specific payer before scheduling. Approval rate ranges reflect data across major commercial payers.
Prior Authorization by Insurance Company — What You Actually Need to Know
Not all insurers carry equal PA burden. The spectrum runs from traditional Medicare (lowest PA burden) to Anthem/Elevance and Centene/Ambetter (highest denial rates and broadest requirements). Here is what matters for each major payer category in 2026.
United Healthcare (UHC) — Vendor: AIM Specialty Health
UHC is the largest commercial insurer in the US. They made notable reductions in 2025–2026, eliminating PA for echocardiography and nuclear cardiology imaging on commercial plans. For surgical procedures — orthopedics, spine, bariatric — UHC uses AIM Specialty Health (uhcprovider.com). AIM’s portal enables real-time decisions for straightforward, well-documented cases. UHC applies InterQual criteria for medical necessity. A gold card program exists for providers with 90%+ historical approval rates — contact your UHC provider advocate to assess eligibility.
Anthem / Elevance Health — Vendor: AIM Specialty Health
Anthem consistently ranks as the payer with the broadest PA requirements and highest denial rates in our dataset. Anthem requires PA for more procedure categories than any other national commercial insurer, including GI and ENT procedures that most competitors do not PA. All Anthem submissions route through AIM via Availity (availity.com). The gold card program at Anthem is real and worth pursuing if your practice has sufficient volume. For spine surgery, some Anthem plans require a pre-surgical psychological evaluation before approving lumbar fusion — worth anticipating early.
Florida Blue (GuideWell) — Radiology Vendor: Evolent/RadMD
Florida Blue uses a split PA infrastructure. Radiology PA (MRI, CT, PET, cardiac imaging) routes through Evolent/RadMD at 1-888-642-2583. Surgical and musculoskeletal PA also routes through Evolent, submitted via Availity. Florida Blue requires PA for advanced imaging, orthopedic surgery, behavioral health admissions, home health, DME, specialty drugs, and bariatric surgery. Turnaround: 1–3 days for radiology and 5–10 days for surgical procedures.
Premera Blue Cross & Regence — Shared Vendor: Carelon
Both Premera (Washington and Alaska) and Regence (WA, OR, ID, UT) use Carelon (formerly AIM Specialty Health) for cardiovascular, radiology, musculoskeletal, and sleep medicine PA. This is operationally significant: one portal serves both payers. Both update their PA requirement lists monthly — making this one of the most important categories to reverify regularly. Emergency services never require pre-authorization from either Premera or Regence.
CareSource — Medicaid Managed Care Across 8 States
CareSource operates Medicaid and Marketplace plans in Ohio, Georgia, Indiana, Kentucky, West Virginia, Missouri, North Carolina, and additional markets. As a Medicaid MCO, CareSource applies stringent PA requirements for surgical procedures, behavioral health, and specialty medications. Submit via Availity or the CareSource provider portal (1-800-488-0134). PA turnaround averages 3–7 days. Document functional disability and medical necessity thoroughly for all CareSource surgical PA requests.
Independence Blue Cross — Vendor: AIM Specialty Health
Independence Blue Cross, serving the Philadelphia area, uses AIM Specialty Health for imaging and musculoskeletal PA programs. IBC requires PA for inpatient admissions, surgical procedures, advanced imaging, behavioral health, specialty drugs, home health, and DME. Access via Availity. IBC has moderate PA burden — higher than Cigna or Humana for most specialties, lower than Anthem or Highmark.
Traditional Medicare — Lowest PA Burden, but OPD Rules Apply
Traditional Medicare FFS does not require PA for the vast majority of clinical services. However, the CMS OPD PA program requires PA for specific procedures performed in outpatient hospital settings: blepharoplasty (CPT 15820–15822), rhinoplasty (CPT 30400–30420), panniculectomy (CPT 15830), vein ablation, spinal neurostimulators, cervical fusion with disc removal, facet joint interventions, and botulinum toxin. These procedures do NOT require PA when performed in an ASC or physician office — only in the outpatient hospital setting.
7 Evidence-Based Strategies to Get Prior Authorization Approved
These strategies are drawn from payer policy analysis and operational feedback from practices that have refined their PA workflows. Implementing them will measurably improve your approval rate and reduce time-to-decision.
Portal submission reduces PA decision time by 35–50%. UHC’s AIM portal, Aetna’s Evicore portal, and Carelon’s system all support real-time or same-day decisions for well-documented cases. Portal submissions also create a documented, timestamped audit trail — critical for appeals. Practices that migrate from fax/phone to portal report fewer lost PA requests and significantly faster decisions.
“Patient has tried physical therapy” will not satisfy medical reviewers. What will: “Patient completed 12 sessions of physical therapy from [date] to [date], focusing on strengthening and ROM. Patient trialed NSAIDs (naproxen 500mg BID × 3 months), received corticosteroid injection on [date] with relief lasting only 3 weeks. VAS pain score at rest: 7/10. Functional limitation: unable to walk more than one block or climb stairs.” Specificity removes subjective interpretation from the review and directly addresses payer criteria.
Payer reviewers match ICD-10 codes to clinical documentation. If you bill M17.11 (primary osteoarthritis, right knee) but your note doesn’t mention OA severity, X-ray findings, or functional limitations, that mismatch is grounds for denial. Write notes that explicitly connect: diagnosis → objective findings → functional impact → proposed treatment → why this treatment over alternatives. This alignment eliminates the most common technical denial reason.
Submitting PA the day before a scheduled procedure is the most common cause of last-minute case cancellations. Build PA submission into your scheduling workflow at the point of surgical booking. Targets: 10 business days for spine/bariatric/transplant, 5–7 days for orthopedic and cardiac, 2–3 days for imaging and pain procedures. Practices that treat PA as a scheduling prerequisite report significantly fewer cancellations.
Peer-to-peer review overturns 60–80% of PA denials across surgical specialties. Yet most practices don’t request it consistently, citing physician time constraints. The solution is operational: have your PA coordinator gather documentation, schedule the P2P time slot with the payer, and brief the physician with a one-page clinical summary. With proper preparation, most P2P calls take 10–15 minutes and are among the highest-ROI uses of physician time. See the Peer-to-Peer Review section below.
Most payers publish their clinical coverage policies publicly: UHC at uhcprovider.com, Aetna’s clinical policy bulletins at aetna.com, Anthem’s guidelines at providers.anthem.com. Citing the specific payer criteria your patient meets — by policy name and number — signals a clinically sophisticated submission that is significantly harder to deny on “medical necessity” grounds than a generic clinical note.
PA reference numbers are your legal protection in disputes and audits. Build a simple PA tracking log: CPT code, payer, submission date, reference number, decision date, approval/denial, and appeal status. Practices with formal PA tracking systems report 23% fewer unexpected denials and significantly faster resolution of disputed claims.
2026 PA Reform Rules: What Changed and What It Means for Your Practice
The prior authorization landscape is changing faster in 2025–2026 than at any point in the past decade, driven by a combination of CMS regulation and voluntary industry commitments from AHIP.
Peer-to-Peer Review: The Most Underused PA Reversal Tool
Peer-to-peer (P2P) review is the process where the treating physician speaks directly — typically by phone — with the payer’s medical director or reviewing physician to discuss a denied or pending PA. It is the single most effective first-line tool for overturning PA denials, with documented overturn rates of 60–80% across surgical specialties.
Despite this, only about 38% of practices consistently request P2P after a denial (AMA, 2023). The most cited reason: physician time. The solution is operational — and the economics justify it. A 15-minute P2P call that overturns a $12,000 surgical authorization is worth more per minute than almost any other activity a physician does that day.
How to Request Peer-to-Peer Review — Step by Step
- Request within the deadline. Most payers require P2P requests within 30–60 days of the denial date. Check the denial letter for the specific deadline — missing it forecloses this option entirely.
- Specifically request a peer-to-peer review. Call the PA department and use the words “peer-to-peer review.” P2P and formal appeal are different processes — P2P is faster and resolves 60–80% of denials without escalation.
- Request a same-specialty reviewer. Under the 2026 AHIP voluntary commitments, you have the right to request a reviewer in the same or related specialty. An orthopedic surgeon should not be reviewed by an internist.
- Prepare your clinical talking points before the call. Know which specific criteria the payer cited for denial and address each with objective clinical data: imaging reports, functional scores, conservative care timeline, and relevant specialty society guidelines.
- Document the call completely. Date, time, reviewer name, their specialty, what was said, and outcome. This is essential evidence if you proceed to formal appeal.
Gold Card Programs: PA Exemptions for High-Performing Providers
A gold card program exempts providers with a consistently high PA approval rate from routine PA requirements for certain procedure categories. As of June 2026, the following major payers offer gold card programs:
Texas enacted the first state-level gold card law in 2021, requiring payers to exempt qualifying physicians from PA for procedures with 90%+ approval rates. As of 2026, similar legislation has passed or is pending in over 20 states. Contact your state medical association for current status — you may be legally entitled to PA exemption.
Medicare vs. Commercial Prior Authorization: Key Differences Every Practice Must Know
Does Medicare require prior authorization?
Traditional Medicare fee-for-service (FFS) does NOT require prior authorization for most services. However, Medicare requires PA for specific procedures in outpatient hospital settings under the CMS OPD PA program. Medicare Advantage plans — operated by private insurers — can and do require PA, often with requirements that are comparable to or stricter than commercial plans. Never assume a Medicare patient doesn’t need PA without first confirming whether they have traditional Medicare or Medicare Advantage.
The critical operational distinction: Traditional Medicare FFS (run by CMS, lowest PA burden) vs. Medicare Advantage (run by private insurers — UHC, Humana, Aetna, Anthem — substantially higher PA burden). A 2023 OIG report found that Medicare Advantage plans denied 13% of PA requests that would have met traditional Medicare coverage criteria — a significant gap that affects thousands of patients annually.
A practical identification rule: if the patient’s card shows only the red, white, and blue Medicare design with a Medicare Beneficiary Identifier (MBI number), that’s traditional Medicare FFS. If there’s a private insurer logo alongside the Medicare logo, that’s Medicare Advantage — verify PA requirements before scheduling anything beyond a routine office visit.
More Prior Authorization Questions — Answered
How long is a prior authorization valid?
Most prior authorizations are valid 90 to 180 days from the approval date, though this varies by payer and service type. Behavioral health PA for ongoing psychotherapy may require concurrent review every 8–12 sessions. DME approvals may be valid for 12 months. As of January 2026, major payers committed to honoring existing PA for 90 days when patients switch plans. Always check the validity period on the PA approval notice and schedule procedures before expiration — expired PA requires a full new submission.
What is the difference between prior authorization and benefits verification?
Benefits verification confirms that a service is covered under the patient’s plan and determines their cost-sharing. Prior authorization confirms that the specific service is medically necessary per payer criteria and that the payer will pay for it. A service can be a covered benefit and still require PA — and without PA, the payer may deny payment even if the service is technically covered. Always complete both steps before high-cost procedures.
Can a prior authorization denial be appealed?
Yes. Every PA denial must include the denial reason and information about the appeals process per state and federal law. Start with peer-to-peer review — this is not a formal appeal but resolves 60–80% of denials without escalation. If P2P fails, file a first-level formal appeal within the payer’s deadline (typically 60–180 days from the denial date). Second-level appeals go to an external independent review organization (IRO). For Medicare Advantage, there is a five-level appeals process including ALJ hearings and federal court review.
Does Ambetter require prior authorization?
Yes. Ambetter is an ACA Marketplace plan operated by Centene Corporation. Ambetter requires prior authorization for surgical procedures, inpatient admissions, advanced imaging, behavioral health services, specialty medications, home health, and DME. Centene uses Evolent for musculoskeletal, cardiac, and radiology PA, and Magellan Health for behavioral health PA in many states. PA requirements are state-specific — submit via the Centene/Ambetter provider portal or Availity.
What is Evicore and which payers use it for prior authorization?
Evicore (now part of Evernorth/Cigna) is one of the largest specialty benefit management organizations in the US, managing PA for radiology, musculoskeletal, oncology, and other specialty services. Payers using Evicore include Aetna (imaging and musculoskeletal), Cigna, Anthem in some markets, TRICARE, and several BCBS plans. Submit Evicore PA at evicore.com/provider or through Availity. One portal login may handle PA for several of your insurers — a meaningful administrative efficiency.
How do I find out if a CPT code requires prior authorization?
Use the PA Check tool at the top of this page — enter the CPT code, select the insurer, and get immediate PA guidance for 500+ CPT codes across 30+ payers with no login required. For codes not in the tool, check directly with the payer: (1) use the payer’s online provider portal, which lists PA-required codes; (2) call the provider services number on the back of the member’s ID card; or (3) check Availity’s Eligibility and Benefits tool. Always verify 5–10 business days before scheduling elective procedures.
Does Geisinger Health Plan require prior authorization?
Yes. Geisinger Health Plan, serving Pennsylvania, requires prior authorization for surgical procedures, advanced imaging, inpatient admissions, behavioral health services, specialty drugs, home health, and DME. Submit via Availity or the Geisinger Health Plan provider portal. Geisinger has moderate overall PA burden. In-network Geisinger providers may benefit from streamlined PA processes through the integrated provider-health plan structure. Provider services: 1-800-447-4000.
Disclaimer: This guide is for informational purposes only and does not constitute legal or medical advice. PA requirements change frequently — always verify with the payer before scheduling procedures. PA Check data is based on 2026 payer policies, CMS OPD PA program guidance, AHIP voluntary commitments (April 2026), and monthly PA requirement lists from Premera and Regence. This tool does not guarantee coverage or payment. Last reviewed: .