Prior Authorisation for Mental Health — What It Is and How to Handle It
Prior authorisation — also called pre-authorisation or pre-certification — is when your insurance company requires you to get approval before receiving certain mental health services. Understanding when it applies and how to navigate it prevents treatment delays and unexpected bills.
When Does Mental Health Require Prior Authorisation?
Prior authorisation requirements vary by plan. Common situations requiring pre-approval:
- Inpatient psychiatric hospitalisation
- Intensive outpatient programmes (IOP)
- Partial hospitalisation programmes (PHP)
- Certain medications (especially brand-name psychiatric drugs)
- Some outpatient therapy beyond a certain number of sessions
Standard outpatient therapy: Many plans do not require prior authorisation for routine outpatient individual therapy sessions, particularly for the first several visits. After a certain number of sessions, some plans require continued service authorisation — approval to continue treatment.
How to Request Prior Authorisation for Mental Health Services
Step 1: Determine if prior authorisation is required by calling your insurance member services number before scheduling the service.
Step 2: Your treating provider (therapist, psychiatrist or facility) typically submits the prior authorisation request on your behalf. Provide them with your complete insurance information.
Step 3: The request includes clinical documentation supporting medical necessity — diagnosis, treatment plan, reason the requested level of care is appropriate.
Step 4: Your insurer typically responds within 14 days for non-urgent requests or 72 hours for urgent requests.
What to Do If Prior Authorisation Is Denied
Request the denial reason in writing — the insurer must provide the specific clinical criteria used and instructions for appeal.
Have your provider submit additional clinical documentation if requested.
File an internal appeal with your insurer citing the medical necessity documentation and any relevant clinical guidelines.
Reference mental health parity: If your insurer applies stricter prior authorisation requirements to mental health than to comparable medical services, this may be a parity violation. Include this argument in your appeal.
Request external review if the internal appeal fails.
Continued Service Authorisation
For ongoing outpatient therapy, some insurers require periodic continued service authorisation — typically every 8 to 16 sessions. Your therapist submits documentation demonstrating continued medical necessity.
If continued authorisation is denied: This means the insurer believes you no longer need therapy. You have the right to appeal this determination, and your therapist’s clinical documentation of ongoing need is essential to a successful appeal.
Frequently Asked Questions
Can I start therapy while waiting for prior authorisation?
This is risky — if you receive services before prior authorisation is obtained and the request is ultimately denied, you may be responsible for the full cost. In urgent situations, discuss options with your provider and insurer. Some plans have expedited authorisation processes for urgent mental health needs.
Does prior authorisation guarantee coverage?
No. Prior authorisation confirms the service is approved for coverage if medically necessary and delivered by an in-network provider under the specified conditions. The actual claim is still subject to your deductible, copay and other plan terms.
Medical Disclaimer: Information on TherapyInsuranceGuide.com is for educational purposes only. Prior authorisation rules vary by plan — always verify requirements with your specific insurer before receiving services.