Prior authorisation: getting treatment approved before it happens

Why insurers use it, and what follows from that

The Spanish term is autorización previa, and the machinery behind it is short. You, your doctor or the hospital submits the proposed treatment; the insurer checks it against your policy; and if it agrees, it issues an approval reference, which the provider then quotes when it treats you and again when it bills.

Insurers use the step for three purposes, and those purposes explain most of the behaviour you will meet at a hospital desk. Cost control: it is where an insurer sees an expensive item before committing to it, rather than in an invoice a month later. Contract checking: it is where exclusions, waiting periods and limits get applied. Network routing: it is where the insurer confirms your chosen provider is one it has an agreement with.

The middle purpose carries a legal consequence worth learning once. Under Spanish insurance contract law, a clause that limits your rights as the insured has to be highlighted specially in the policy and specifically accepted by you in writing. So whenever you are told that something is restricted, capped or excluded, a clause sits behind that answer and you are entitled to be shown it. Which clause is that? is an ordinary, answerable question, and asking it changes the tone of the conversation more than any amount of argument does.

Authorisation is therefore not a formality. It is the moment your cover is decided for that episode.

Referral and authorisation are not the same thing

These are confused constantly, including by people who work in clinics.

A referral is a clinical instruction. In Spain you are often handed a volante — a request slip — on which a doctor writes the test or specialty you should go to next. It says a doctor thinks you need something, and carries no financial meaning at all. An authorisation is a financial and contractual decision by your insurer: it will pay for that thing, on your policy, at that provider, within a defined period.

You can hold a perfectly valid referral for something your policy does not cover, or will only cover elsewhere. The two travel together in most episodes, which is exactly why people assume they are one document.

What typically needs it, by setting

The pattern below is typical of Spanish private products. It is a shape to check your own policy against rather than a list to rely on; the binding version is the schedule of services in your own conditions, and the last section of this page says where that sits.

Setting	Typically needs authorisation?	Who usually requests it
Routine consultation with a network specialist	Usually not	Nobody — you book directly
Basic tests ordered by a network doctor (blood, urine, plain X-ray)	Usually not	The clinic, if anything
Complex imaging — MRI, CT and similar	Commonly yes	The requesting doctor’s clinic, or you
Invasive diagnostics — endoscopy, biopsy, catheter studies	Commonly yes	The performing clinic
Courses of physiotherapy or rehabilitation	Commonly yes, approved in blocks	The clinic or you
Outpatient and day surgery	Commonly yes	The hospital’s admissions office
Planned inpatient admission and surgery	Almost always	The hospital, with the surgeon’s report
Prostheses, implants and surgical materials	Usually yes, and often separately	The surgeon or hospital
Emergency admission	Notification rather than approval, often after the event	The hospital, or whoever is with you

Two patterns are worth noticing. Authorisation clusters around what is expensive, invasive or open-ended; a course of sessions is open-ended, which is why courses are approved in defined blocks. And the requester shifts towards the provider as the setting gets more serious. Nobody expects a patient to arrange their own surgical authorisation, but plenty are left to chase their own scan.

Who initiates the request

Three models exist, used in different settings. The provider does it: usual for admissions and surgery, handled by the hospital’s admisión or authorisations desk. What happens at a private hospital admission follows that through the door. Your doctor’s clinic does it: usual for scans ordered in consultation, by sending the report on your behalf. You do it: increasingly common, because insurer apps let you upload the report yourself, and often fastest, since nothing sits in a clinic’s outbox.

The failure mode is the gap between models: the clinic assumes you will send it, you assume the clinic has, and nobody does. One question before you leave the consultation closes it: who is sending this to my insurer, and how will I know it has been approved?

The sequence, and what you will be asked for

A typical request runs like this.

1. A clinician documents the need in an informe médico, a medical report naming the diagnosis or suspected diagnosis, the treatment proposed and the reasoning. A bare request slip with only a procedure name on it is the commonest cause of a bounced request.
2. The request is submitted with your policy number, your identification, the provider and the intended date.
3. The insurer assesses it against your cover, waiting periods, exclusions and whether the provider and professionals are in network. High-cost cases may go to a medical adviser.
4. A decision issues, usually an approval reference, sometimes with conditions or a named provider attached, always with a validity period.
5. The provider quotes the reference when it treats you and when it bills.

Keep your own copy. Providers lose them, dates move, and a reference in your phone has settled more admissions-desk disputes than any amount of arguing.

How long it takes, and how to chase

Turnaround is set by product and complexity: outpatient diagnostics are usually decided quickly, a surgical case needing a medical adviser’s review takes longer. Your policy conditions or member guide state the timescale your insurer works to, and that is the number to plan around rather than a figure from a forum.

More useful than the headline number is knowing when the clock started. Chase in order: confirm with the clinic that the request was actually sent, and when; then with the insurer that it was received, and in what state; then ask what is outstanding. Most delays are not decisions being agonised over. They are requests never transmitted, or requests that arrived without the report.

Urgent and emergency situations

Emergencies are the deliberate exception. Nobody expects a patient having a heart attack to obtain approval first. Emergency care is dealt with under its own rules and the paperwork becomes retrospective notification rather than prior approval: you, your family or the hospital tell the insurer as soon as practical that an admission has happened. Spanish insurance contract law sets a backstop, requiring the insured to notify the insurer of a claim within seven days of becoming aware of it unless the policy allows longer, and products usually specify their own, often shorter, window and channel. Find yours before you need it, not from a hospital corridor.

Note too that an emergency turning into planned treatment stops being an emergency: the admission may be handled retrospectively while surgery scheduled three days later still needs authorising normally. And know which hospitals your policy sends you to when there is a genuine choice, because “nearest emergency department” and “in your network” are not always the same building.

Refused, downgraded, or simply missing

Refused. Ask for the reason in writing, and which clause it rests on. A refusal for a missing medical report is administrative, and your doctor can fix it in an afternoon. A refusal on an exclusion or an unexpired waiting period is a coverage decision, and it points at your policy conditions. If you still disagree, ask for the formal complaints procedure and use it in writing. Disputes are won on documentation.

Downgraded. Approval sometimes issues for less than was asked: a shorter block of sessions, a different provider, a less expensive technique. This is easy to miss, because the message says “approved”. Read what was actually approved before assuming it matches the request.

Simply missing. The commonest outcome, and rarely a deliberate decision. Nothing was refused; nothing was sent. Treat silence as an unsent request until someone shows you otherwise.

What an authorisation does not cover

An authorisation approves a defined treatment, at a defined provider, within a defined period. It does not silently extend to everything happening around it:

• Materials, prostheses and implants, frequently approved by their own route and carrying their own limits.
• Other professionals in the same episode: the anaesthetist, the surgical assistant, the laboratory, the pathologist reading a biopsy. Each may hold its own arrangement with your insurer, or none, and can invoice you separately even when the procedure was fully approved.
• Room supplements and hotel-style extras, which sit outside the medical authorisation and are usually what you sign for at the admissions desk.
• Anything that changes on the day. If the treatment done differs from the treatment approved, or the date slips past the validity period, the authorisation no longer describes what happened.

Surgery is where those four gaps do the most damage, because an operation involves the most separate parties. The surgical journey has its own guide and this page does not repeat it: private surgery in Spain, step by step covers who has to say yes, what “partly covered” can mean, and the questions to put before an operation is booked.

• Follow-up: post-operative consultations, rehabilitation and further imaging are all separate events with their own rules.

Questions worth asking your insurer

Ask these once, early in the policy, and you will not have to ask them under pressure. Which services on my product require prior authorisation? How do I submit a request, and what must go with it? What turnaround do you work to, and how do I check a request’s status myself? How long is an approval valid, and what if my date moves? What must I do after an emergency admission?

Where your own list actually lives

Everything above describes a common shape, and the variation between products is real, so at some point you have to stop reading about the typical case and go and read yours. Three documents hold the answer between them. The condiciones generales set out the services subject to prior authorisation and the terms attached to them. The condiciones particulares say which of those apply to the product you bought, in your name, with your start date. The schedule of limits carries any caps. Where those disagree with anything on this page, they win.

Two features of your own cover change how often you will meet this step at all. A plan built around a medical network handles the money differently from one built around reimbursement of your own invoices. And waiting periods and pre-existing conditions both surface here, because authorisation is the point at which a policy’s limits meet a real request.