What prior authorization means

Prior authorization for wound care means your insurance plan reviews a planned service, supply or piece of equipment and decides whether to approve it before it is provided. You may also hear it called preauthorization, precertification or prior approval.

It is not the same as a referral, which comes from a clinician. An authorization comes from the plan. Our guide on whether you need a referral for wound care explains the difference.

What may need approval in wound care

Every plan keeps its own list. Plans sometimes ask for approval before:

  • Advanced products, such as a skin substitute
  • Equipment, such as a pump for negative pressure wound therapy or a pressure-relieving mattress
  • Home health nursing
  • Certain tests, imaging or specialist procedures
  • Care from a provider outside the plan’s network

In general, Original Medicare uses prior authorization for a limited list of items and services. Medicare Advantage plans, Medicaid health plans and commercial plans tend to use it more widely. Ask your plan what applies to the care your clinician has recommended.

Who does what

  • The treating clinician decides what care you need and writes the order.
  • The treating practice or the supplier usually sends the request to the plan, along with notes that explain why the care is needed.
  • The plan reviews the request, makes the decision and notifies the office and you.
  • Gateway arranges care in Greater St. Louis and the Metro East and helps keep records and messages moving between the offices involved, including wound supply and equipment coordination. We do not decide requests, and we cannot promise an approval.
  • You keep your insurance information current, answer calls and confirm that a request was sent.

Not sure which office to call? See the insurance page or request a call back.

The steps in a typical request

  1. The clinician orders a service, product or piece of equipment.
  2. The practice or supplier checks whether your plan requires approval for it.
  3. The office sends the request with supporting records. For a wound, that often means measurements over time, what has already been tried and the clinician’s notes.
  4. The plan reviews it and may ask for more information.
  5. The plan approves the request, denies it or approves part of it, and sends notice of the decision.

A request for more information is not a denial, but the request waits until someone responds. Ask who is handling it.

How patients and families can help

You usually do not submit the request yourself, but you can keep it from stalling.

  • Give the practice and the supplier your current insurance card, front and back, through the channel they ask you to use. Do not put card details in a website form.
  • Tell every office right away if your plan changes. Many changes take effect in January.
  • Return calls from the plan, the practice and the supplier.
  • Keep scheduled visits. Plans often want recent measurements and notes.
  • Ask for the authorization or reference number and write it down.
  • Ask when the approval ends and who will request a renewal.

A wound care visit notebook is a good place to keep these details.

What an approval does and does not tell you

An approval is specific. It names a service or item, an amount or number of visits, a date range and often a particular provider or supplier. If any of those change, a new request may be needed.

An approval is also not a promise that the plan will pay the whole bill. Payment still depends on your eligibility and benefits on the day of service, including any deductible, copay or coinsurance. See our list of insurance and cost questions for wound care.

If a request is denied or delayed

Ask the plan for the decision and the reason in writing. The notice should explain how to appeal and the deadline for doing so. Tell the treating practice or supplier, because the clinician may be able to send more records or speak with the plan’s reviewer.

If the clinician believes that waiting could seriously harm your health, ask the plan whether it offers a faster review. While a request is pending, ask the clinician what the plan is for your wound in the meantime.

Report any worsening, such as spreading redness, fever, more drainage or increasing pain, without waiting for the plan. Emergency care does not wait for an approval. If you think you are having an emergency, call 911.

Common questions

How long does a prior authorization decision take?

It depends on the plan and on the kind of request, and nobody outside the plan can promise a date. Plans have their own timeframes and may move faster when a clinician marks a request as urgent. Ask the plan when to expect a decision and how you will be notified.

Can wound care continue while an authorization is pending?

Often part of it can. A pending request usually concerns one item or service, and the rest of your care may not need approval. The treating clinician decides what is appropriate in the meantime. If you are offered an item before the plan decides, ask in writing what you would owe if the request is denied.

Does an approval carry over if I change insurance plans?

Usually an approval belongs to the plan that issued it. A new plan may want its own request, even for care you are already receiving. Tell the treating practice and your suppliers as soon as you know your coverage is changing, and ask the new plan whether it has transition rules for ongoing treatment.

The plan approved fewer visits or supplies than the clinician ordered. What now?

Ask the plan to explain in writing what was approved and why. Then tell the treating practice or supplier. The clinician can decide whether to send more information, request the rest later or adjust the plan of care. You can also ask the plan how to appeal the part that was not approved.

Related pages

General information to help you talk with your own clinician. It is not medical advice, and the treating clinician makes every clinical decision. For a medical emergency, call 911.

Updated October 2026