What is typically required for a service to be covered by insurance?

For a service to be covered by insurance, prior authorization is usually required for specific treatments, procedures, or medications. This process involves obtaining approval from the insurer before the service is provided to ensure that it meets the recommended medical necessity criteria according to their policies. The rationale behind requiring prior authorization is to manage healthcare costs effectively and make sure that the proposed services align with accepted clinical standards.

While referrals from a primary care physician can be necessary for certain types of care, such as specialist visits, they are not universally required across all insurance plans or services. Co-payment arrangements pertain to cost-sharing between the insured and the insurer but do not determine whether the service will be covered initially. Pre-existing condition waivers relate to the coverage of conditions present before obtaining insurance and largely pertain to the eligibility of coverage rather than the authorization for a specific service.

Therefore, prior authorization stands out as the correct requirement for service coverage, as it is fundamentally tied to the approval process necessary for certain medically necessary treatments and procedures under many insurance plans.