General

Prior authorization

Insurer approval required before certain services are covered.

How the laws define this

At its core, prior authorization represents a mandatory pre-approval mechanism where permission must be obtained from a designated authority before a specific action, service, or tool is permitted, provided, or covered. The fundamental divergence among these texts lies in the domain and subject matter to which this requirement applies. In healthcare insurance contexts—such as Arizona HB 2175, an Alabama act relating to health insurance, the Ensuring Transparency in Prior Authorization Act, and guidance titled Making improvements to transparency and accountability in the prior authorization determination process—approval must be granted by an insurer, health benefit plan, or utilization review agent before medical services, treatments, or prescription drugs are covered or reimbursed. In contrast, under the Georgia State AI Governance and Use Guidance, the concept applies to internal government operations, requiring state entities and employees to secure explicit approval from the Georgia Technology Authority before regularly using generative AI tools for organizational purposes.

Synthesised from the 5 statutory definitions below. Each one is quoted in full, with its source.

How jurisdictions differ

What is distinctive in each definition, binding law in force first. Showing 4 of the 5 instruments that define this term; all are listed under Definitions below.

Jurisdiction	Instrument	Status	What is distinctive
Arizona, United States	Arizona HB 2175 — Healthcare AI Insurance Claim Denial Restrictions	In Force	Adds that denials from prior authorization determinations trigger the statute's review and signature requirements.
Washington, United States	Making improvements to transparency and accountability in the prior authorization determination process.	In Force	Plain definition limited to approval by health insurance carriers before covering medical services, treatments, or prescription drugs.
Nebraska, United States	Adopt the Ensuring Transparency in Prior Authorization Act and provide for insurance and medicaid coverage of biomarker testing	In Force	Specifies approval from a patient's health plan or utilization review agent before a service or medication is provided or covered.
Alabama, United States	An Act, Relating to health insurance; to impose limitations on the use of artificial intelligence by health benefit plan providers in making determinations of coverage under health benefit plans; and to authorize the Department of Insurance of the State of Alabama to investigate and impose disciplinary action for violations.	Awaiting Entry	Defines it as a determination of medical necessity or satisfaction of plan requirements for payment or reimbursement.

What it triggers

In Arizona, denials arising from prior authorization determinations implicate the statute's review and signature requirements.source
In Washington, health carriers are prohibited from using AI as the sole basis for denying prior authorization.
In Nebraska, health insurers and Medicaid providers are prohibited from using AI as the sole basis for denying prior authorizations.source
The Georgia State AI Governance and Use Guidance sets out that state entities and employees obtain explicit approval from the Georgia Technology Authority before regularly using generative AI tools.source

Definitions (5)

An insurer approval process required before specified medical services, procedures, or treatments will be covered by the health plan; denials arising from prior authorization determinations implicate the statute's review and signature requirements.

Arizona HB 2175 — Healthcare AI Insurance Claim Denial RestrictionsDefinition 1 of 5

Prior authorization mandates that state entities and employees obtain explicit approval from the Georgia Technology Authority (GTA) before regularly using generative AI tools for organizational purposes. This requirement ensures controlled and compliant integration of AI.

Georgia State AI Governance and Use GuidanceDefinition 2 of 5

A process required by health insurance carriers where approval must be obtained before a medical service, treatment, or prescription drug is covered.

Making improvements to transparency and accountability in the prior authorization determination process.Definition 3 of 5

A written or oral determination made by a health benefit plan provider that a health care service is a benefit covered under the applicable health benefit plan which, under the enrollee's clinical circumstances, is medically necessary or satisfies another requirement imposed by the health benefit plan provider or law and thus satisfies the requirements for payment or reimbursement.

An Act, Relating to health insurance; to impose limitations on the use of artificial intelligence by health benefit plan providers in making determinations of coverage under health benefit plans; and to authorize the Department of Insurance of the State of Alabama to investigate and impose disciplinary action for violations.Definition 4 of 5

Prior authorization refers to the process by which a healthcare provider must obtain approval from a patient's health plan or utilization review agent before a service or medication can be provided or covered. This process is central to the Act's regulatory scope, as it seeks to reform the criteria, timelines, and methods by which these approvals are granted or denied.

Adopt the Ensuring Transparency in Prior Authorization Act and provide for insurance and medicaid coverage of biomarker testingDefinition 5 of 5

Not to be confused with

Written denial

Written denial is the documented denial with explanation and physician signature that may result from a prior authorization process.

Medical necessity

Medical necessity is the standard used within prior authorization to determine if a service is appropriate and covered.

Questions and answers

What triggers review requirements in Arizona prior authorization?

Denials arising from prior authorization determinations implicate the statute's review and signature requirements. This applies under Arizona HB 2175.

Does prior authorization involve AI restrictions in Washington?

Washington SB 5395 prohibits health carriers from using AI as the sole basis for denying prior authorization, requiring human oversight.

What is prior authorization for state AI use in Georgia?

It describes a process where state entities and employees obtain explicit approval from the Georgia Technology Authority before regularly using generative AI tools.