Check and track a family health insurance prior authorization

The short answer

In medical billing, prior authorization means the health plan must review and approve certain services, procedures, medications or equipment before it agrees to cover them. Usually the clinician's office or the pharmacy submits the request, and the insurer issues a decision. As a family coordinator, your job is to confirm that a request was sent, find out its current status through the insurer's official channels, and keep a record of reference numbers, contacts and next steps so nothing stalls between offices.

This guide covers the administrative side only: terms, status checks and record keeping. Whether a treatment is medically appropriate is a question for the clinician.

What prior authorization means in practice

A prior authorization is a coverage check that happens before care, not a medical decision about whether the care is needed. The plan reviews the request against its coverage rules and either approves it, denies it, approves part of it, or asks for more information. If a required authorization is missing, the claim may be denied or the family may face a larger bill, so it helps to confirm early.

An approval is usually limited. It may cover specific dates, a set number of visits or units, a particular provider or facility, and specific service codes. Many plans also state that approval does not by itself guarantee payment, because eligibility, benefits and claim details are checked again when the claim arrives. Record those limits when you hear them.

Other names you may hear

Offices and insurers use several terms for essentially the same process: preauthorization, precertification (often shortened to precert), prior approval, and sometimes pre-service review. For prescriptions, pharmacies may call it a drug prior authorization or a coverage review. When someone uses an unfamiliar term, ask whether it refers to the authorization for this specific request or to something else, such as a referral, a benefits check or a claim.

Who does what

• Person receiving care: the plan member. Their member ID, consent and, where required, signed permission allow others to speak with the insurer on their behalf.
• Family coordinator: tracks status, keeps records, relays information between offices and the person receiving care, and follows up when something stalls.
• Clinician's office or pharmacy: usually prepares and submits the request with supporting medical information, and responds if the insurer asks for more.
• Insurer or its pharmacy benefit manager: reviews the request, issues the decision and explains what remains outstanding.

Before calling, ask the insurer what permission it needs on file to discuss the member's account with you. Many plans will only speak with a family member after the member authorizes it or designates a representative, so setting this up ahead of time avoids a wasted call.

How to check prior authorization status with Cigna

Cigna offers several routes, but the right one depends on the specific plan, so start with the member's current ID card and plan documents rather than a general search.

• 1. Look at the current member ID card. Note the member ID, group number, and the member services and pharmacy phone numbers printed on it. If the card lists a separate pharmacy benefit manager, drug authorizations may be handled there rather than by the medical plan.
• 2. Check the member portal or app. Many Cigna members can see authorization or precertification activity in the myCigna website or app. If you are coordinating for someone else, confirm the member has given you access or is with you when you check.
• 3. Call member services using the number on the card. Have the member ID, the patient's date of birth, the service or medication, the requesting provider's name and the approximate submission date ready.
• 4. Ask the submitting office. The clinician's office or pharmacy can often confirm when they sent the request, the reference number and whether the insurer asked for more information.
• 5. Write down which route answered your question, so the next follow-up goes to the same place.

Plan administration can change, for example when an employer switches administrators or a plan is transferred to another company. If the card, portal and phone menu point to different organizations, ask member services which one currently handles authorizations for this plan.

Clarify what the status actually means

Status words such as pending, in review, pended, approved, partially approved or denied can mean different things depending on who says them. Record the exact wording, who used it and how they explained it. Useful questions:

• What does this status mean for this request?
• Has the request been submitted, and has the insurer received it?
• Is anything missing, and who needs to provide it?
• Is there a deadline, and what does it apply to?
• If approved, what dates, number of visits or units, provider and location does it cover?
• Is this about authorization, coverage, eligibility or a claim?

Write down the answer as given. Avoid guessing at the chances of approval or assuming coverage from a status word alone.

Set up a simple status tracker

One row per request in a spreadsheet, shared document or notebook is enough. Mark anything you have not confirmed as unconfirmed rather than leaving it blank or filling it in from memory.

Column	What to record
Request	Service, procedure, medication or equipment, in plain words
Submitting office	Clinician's office, facility or pharmacy that sent it
Submission date	Date the office reports sending it
Reference number	Authorization or case number from the insurer or office
Checking route	Portal, app, member services line or office contact used
Contact and time	Name or ID of the person you spoke with, date and time
Reported status	Exact words used
Missing item	Anything the contact says is outstanding
Responsible party	Who must act next
Next step	What that party said will happen
Deadline	Date, time zone if relevant, and what it applies to
Follow-up	When you plan to check again and through which route

Keep a call log alongside it

Keep each conversation in a separate call log and note which tracker row it relates to. Before ending a call, read back the reference number, reported status, responsible party and next step. If you are given a deadline, confirm the date, any time zone, the required action and how the item must be submitted. If the provider's office and the insurer give different accounts, keep both and ask the relevant contact to reconcile them rather than choosing one.

Illustrative example

This is a hypothetical case. The clinician's office says the request was submitted on Monday, but the insurer's representative says on Thursday that no request can be found. Record both statements with dates and any reference numbers. Ask the office to confirm where they sent the request and to provide their submission reference, then follow the insurer's stated process for checking again. Keep the row marked unresolved until a further response is recorded.

If the request is denied

Ask the insurer for the decision in writing, the stated reason and the deadline and method for an appeal. Share that information with the person receiving care and the clinician's office, since the office often handles resubmission or supplies records for an appeal. Add the denial reference, the reason given and the appeal deadline to the tracker so the next step and its owner are clear.