How Pre-Authorisation Works for Private Medical Insurance Claims
As FCA-authorised experts in the UK private medical insurance market, WeCovr has helped arrange over 900,000 policies, giving us deep insight into how the claims process works. This guide demystifies pre-authorisation, ensuring you can use your health cover smoothly when you need it most.
Detailed walkthrough of pre-authorisation process, timings, requirements, and what to do if delayed or denied
Navigating a private medical insurance (PMI) claim for the first time can feel daunting. The most critical step in this journey is "pre-authorisation." It's the gateway to accessing private healthcare, acting as the formal approval from your insurer before you undergo tests or treatment.
Understanding this process is not just administrative trivia; it is fundamental to ensuring your medical bills are paid and you avoid unexpected costs. This comprehensive guide will walk you through every stage, from your first GP visit to what to do if your request hits a snag.
What is Pre-Authorisation in Private Medical Insurance?
In simple terms, pre-authorisation is the process of getting a 'green light' from your insurance provider before you receive any non-emergency private medical treatment. It is a mandatory checkpoint where the insurer verifies that the proposed consultation, test, or procedure is both medically necessary and covered under the terms of your policy.
Think of it like getting an official estimate approved before a builder starts work on your house. You wouldn't want them to begin without knowing what's covered and what you'll be paying for. Pre-authorisation serves the same purpose for your health.
Why is pre-authorisation so important?
- Confirms Cover: It ensures the treatment you need is included in your policy, preventing nasty surprises with unpaid bills later.
- Verifies Medical Necessity: Insurers have clinical teams who check that the proposed treatment is the right course of action for your condition.
- Manages Costs: It allows the insurer to confirm that the fees charged by the hospital and specialist are within expected limits. This helps keep the overall cost of insurance down for everyone.
- Guides You to a Recognised Provider: It ensures the consultant and hospital you plan to use are part of the insurer's approved network, guaranteeing a certain standard of care.
The Golden Rule: Acute vs. Chronic and Pre-existing Conditions
Before we go further, it's vital to understand the fundamental principle of UK private medical insurance. Standard policies are designed to cover acute conditions that arise after your policy has started.
- Acute Condition: An illness, injury, or disease that is likely to respond quickly to treatment and lead to a full or near-full recovery. Examples include hernias, cataracts, joint replacements, or infections.
- Chronic Condition: A long-term condition that has no known cure and requires ongoing management or monitoring. Examples include diabetes, asthma, high blood pressure, and arthritis. PMI does not cover the routine management of chronic conditions.
- Pre-existing Condition: Any ailment for which you have experienced symptoms, sought advice, or received medication or treatment before the start date of your policy. These are typically excluded, at least for an initial period (usually two years).
Getting this distinction right is the key to a successful claim. Pre-authorisation will be denied if the condition is found to be chronic or pre-existing and therefore excluded by your policy.
The Step-by-Step Pre-Authorisation Process Explained
While each insurer has a slightly different system, the core journey is largely the same across the UK market.
Step 1: Visit Your GP
Your journey almost always begins with your General Practitioner (GP). Whether you use your local NHS GP or a private GP service (if included in your policy), this is the starting point. You discuss your symptoms, and the GP makes an initial assessment.
Step 2: Get a Specialist Referral
If the GP believes you need to see a specialist (like a cardiologist, dermatologist, or orthopaedic surgeon), they will write you a referral letter. This is arguably the most important document in the entire process. It outlines your symptoms, medical history, and why you need specialist advice.
Step 3: Contact Your Insurer to Request Pre-Authorisation
With your GP referral in hand, it's time to contact your insurance provider. Do not book any appointments yet! Most insurers offer several ways to get in touch:
- By Phone: The most common method. You'll speak to a claims handler who will guide you through the process.
- Online Portal: Many providers have secure member portals where you can upload documents and submit a claim online.
- Mobile App: Leading insurers like Bupa, Aviva, and Vitality have excellent apps that streamline the pre-authorisation process.
Step 4: Provide All the Necessary Information
To approve your request, the insurer will need specific details. Having these ready will make the call or online submission much faster:
- Your policy number
- The full name and date of birth of the patient
- A description of your symptoms and when they first started
- Details of your referring GP
- The name of the specialist you've been referred to (if you have one)
- The name of the hospital or clinic you plan to use
Your insurer may ask for a copy of the GP referral letter, so have it ready to email or upload.
Step 5: The Insurer Reviews Your Request
Once you've submitted your request, the insurer's claims team gets to work. They will:
- Check your policy to confirm you have cover for consultations and diagnostic tests.
- Review the information against your policy's exclusions (especially for pre-existing conditions).
- Confirm that the specialist and hospital are on their recognised list.
For more complex procedures like surgery, a clinical nurse or doctor on the insurer's team will review the case to ensure it's medically appropriate.
Step 6: Receive Your Authorisation Number
If your request is approved, the insurer will give you a pre-authorisation number or authorisation code. This code is your golden ticket. It confirms that the insurer has agreed to cover the costs for that specific stage of treatment (e.g., the initial consultation and any initial tests).
You may get separate authorisation codes for different stages: one for the consultation, another for an MRI scan, and a final one for surgery.
Step 7: Book Your Treatment
Now, and only now, should you call the specialist's secretary or the hospital to book your appointment. You will need to provide them with your pre-authorisation number. This tells them that your insurer will be paying the bill.
Step 8: Invoicing and Payment
After your consultation or treatment, the hospital and specialist will send their invoices directly to your insurance company, quoting your authorisation number. You do not have to handle any bills yourself, with one exception: your policy excess. If your policy has a £250 excess, for example, the insurer will pay the bill minus that amount, and the hospital will typically bill you for the £250 separately.
Key Requirements and Documentation for a Smooth Process
Being prepared can make the difference between an instant approval and a week of frustrating delays.
| Document / Information | Why It's Needed | Pro Tip |
|---|---|---|
| GP Referral Letter | This is the medical justification for your claim. It proves to the insurer that a qualified doctor deems specialist investigation necessary. | Ensure the letter is open (addressed 'To whom it may concern') or to a specialism (e.g., 'Dear Cardiologist') rather than a specific named consultant, giving you more flexibility. |
| Policy Number | Your unique identifier. The insurer cannot do anything without it. | Keep your policy number saved in your phone or have your documents easily accessible. |
| Procedure Codes (CCSD) | For surgery or specific treatments, the consultant's secretary will provide CCSD codes. These are standardised codes for every medical procedure. | When you call your insurer to authorise surgery, have these codes ready. It allows them to give an instant decision as they know exactly what's planned. |
| Consultant & Hospital Choice | Insurers have 'networks' or lists of approved providers they have fee agreements with. Going 'out-of-network' can result in partial payment or no cover at all. | Most insurers have a search tool on their website. Check your chosen specialist and hospital are on the list before starting the pre-authorisation process. |
How Long Does Pre-Authorisation Take? Typical Timelines
One of the main reasons for choosing private healthcare is speed. With NHS waiting lists in England standing at an estimated 7.54 million treatment pathways as of mid-2024, getting swift access to care is a priority for many. The pre-authorisation process is designed to be efficient.
| Type of Request | Typical Pre-Authorisation Time | Notes |
|---|---|---|
| Initial Specialist Consultation | Immediate – 48 hours | Often approved on the initial phone call or within minutes via an app. |
| Standard Diagnostic Tests | Immediate – 48 hours | Simple tests like blood work or X-rays are usually approved quickly. |
| Advanced Scans (MRI, CT, PET) | 24 – 72 hours | May require a quick clinical review to confirm they are justified. |
| In-patient Surgery | 2 – 5 working days | This is more complex and requires review of procedure codes and clinical notes. |
| Complex Cancer Treatment | 3 – 7 working days | Involves detailed review by specialist oncology case managers to approve a full treatment plan. |
Factors that can speed up the process:
- Calling at off-peak times (mid-morning, mid-afternoon).
- Using the insurer's app or online portal, which are often automated.
- Having all your information, including procedure codes, ready.
Factors that can cause delays:
- Missing information on your request.
- The insurer needing to write to your GP for more medical history (this is the most common cause of significant delays).
- Public holidays or busy periods.
Common Reasons for Pre-Authorisation Delays or Denials
It can be distressing to have a claim delayed or denied. Understanding the common reasons can help you avoid them or challenge a decision effectively.
Top Reasons for Denial
- It's a Pre-existing Condition: This is the number one reason for rejection. If you had symptoms or treatment for the condition before your policy started, it will likely be excluded under the terms of your underwriting (either Moratorium or Full Medical Underwriting).
- It's a Chronic Condition: PMI is for curable, acute conditions. The long-term management of conditions like diabetes or asthma is not covered.
- It's a General Policy Exclusion: Every policy has a list of standard exclusions, which almost always include:
- Cosmetic surgery (unless for reconstruction after an accident/cancer)
- Fertility treatment
- Experimental or unproven treatments
- Addiction treatment
- Normal pregnancy and childbirth
- The Provider is "Out-of-Network": The specialist or hospital you've chosen is not on the insurer's approved list, or your policy has a restricted hospital list.
- Policy Limits Reached: Some policies have annual limits on certain benefits, such as out-patient cover for consultations and tests. If you've reached your limit (e.g., £1,000), further claims for that benefit will be denied for the rest of the policy year.
Real-Life Examples:
- Denied Claim (Pre-existing): John takes out a PMI policy in January. In March, he requests pre-authorisation for physiotherapy for back pain. The insurer sees from his GP records that he visited a chiropractor for the same issue the previous year. The claim is denied as it's a pre-existing condition.
- Approved Claim (Nuanced): Maria has well-managed asthma (a chronic condition). She falls and breaks her wrist (an acute condition). Her PMI will not cover her routine inhalers, but it will cover the consultation, X-ray, and surgery for her broken wrist, provided she gets it pre-authorised.
What to Do If Your Pre-Authorisation is Delayed or Denied
Don't panic. A delay or even an initial denial is not always the final word. Here is a clear action plan.
If Your Request is Delayed:
- Follow Up Politely: Call your insurer and ask for an update. Get a reference number for your query and make a note of who you spoke to and when.
- Ask What's Needed: The most common reason for delay is the insurer waiting for more information. Ask them precisely what they are waiting for – is it a report from your GP or more details from the specialist?
- Be Proactive: If they are waiting for a GP report, call your GP surgery to let them know an urgent request is on its way. If they need information from the specialist, call the specialist's secretary and ask them to contact the insurer. A call from one medical professional to another can often resolve things in minutes.
If Your Request is Denied:
- Request the Reason in Writing: Ask the insurer to send you a formal letter or email explaining exactly why the claim was denied, referencing the specific clause or exclusion in your policy document.
- Speak to Your Specialist: Share the insurer's reason for denial with your GP or consultant. They may be able to provide a supporting letter that clarifies the medical situation – for example, arguing that the condition is acute, not chronic, or that the treatment is medically essential.
- Lodge a Formal Appeal: Every insurer has a formal, multi-stage complaints procedure. Your denial letter should explain how to start this process. Submit your appeal in writing, including any new evidence from your specialist.
- Escalate to the Financial Ombudsman Service (FOS): If you have completed the insurer's internal complaints process and are still not satisfied with their final response, you have the right to take your case to the FOS. This is a free and impartial service that settles disputes. You must do this within six months of the insurer's final decision.
The Role of a PMI Broker like WeCovr
Choosing the right policy from the start is the best way to prevent claim issues down the line. This is where an expert, independent broker is invaluable.
A specialist broker like WeCovr doesn't just sell you a policy; we act as your expert guide.
- Market Comparison: We compare policies from across the market, explaining the crucial differences in cover, network access, and claims processes. This helps you choose a policy that genuinely meets your needs.
- Understanding the Fine Print: We help you understand the policy wording around key issues like pre-existing conditions, out-patient limits, and cancer cover, so there are no surprises.
- Application Guidance: We ensure your application is completed accurately, which is vital for the underwriting process and future claims.
- Ongoing Support: While we cannot make a claim for you, we can provide expert guidance if you face a confusing delay or denial, helping you understand the insurer's reasoning and your options for appeal.
Best of all, using a broker like WeCovr costs you nothing. We are paid by the insurer, so you get impartial, expert advice for free.
Health & Wellness: A Proactive Approach to Your Health
The best claim is the one you never have to make. Modern private health cover is increasingly focused on proactive health and wellbeing, with many insurers offering a suite of benefits to help you stay healthy:
- Discounted gym memberships
- Access to mental health support and therapy apps
- Digital GP services available 24/7
- Rewards for healthy living (e.g., tracking steps)
Taking charge of your health is empowering. Simple lifestyle adjustments can have a huge impact. The NHS recommends adults aim for at least 150 minutes of moderate-intensity activity a week and 7-9 hours of quality sleep per night.
As part of our commitment to our clients' wellbeing, WeCovr provides complimentary access to our CalorieHero AI calorie tracking app, helping you manage your diet and nutrition goals effortlessly. Plus, clients who purchase PMI or Life Insurance with us can benefit from discounts on other types of cover.
By using these tools and focusing on prevention, you can reduce your risk of developing certain acute conditions, making your health insurance a safety net rather than a frequently used service.
Can I start treatment before getting pre-authorisation?
Do I need pre-authorisation for every single visit to a specialist?
What happens if I have an excess on my private medical insurance policy?
Navigating the world of private medical insurance UK can be complex, but the pre-authorisation process is a straightforward system designed to protect both you and the insurer. By being prepared and understanding the rules, you can ensure a fast and smooth journey to treatment.
For expert, no-obligation advice and a free comparison of the UK's leading PMI providers, speak to the friendly team at WeCovr today. Get your free, personalised quote and find the perfect private health cover for you and your family.
Related guides
Why private medical insurance and how does it work?
What is Private Medical Insurance?
Private medical insurance (PMI) is a type of health insurance that provides access to private healthcare services in the UK. It covers the cost of private medical treatment, allowing you to bypass NHS waiting lists and receive faster, more convenient care.How does it work?
Private medical insurance works by paying for your private healthcare costs. When you need treatment, you can choose to go private and your insurance will cover the costs, subject to your policy terms and conditions. This can include:• Private consultations with specialists
• Private hospital treatment and surgery
• Diagnostic tests and scans
• Physiotherapy and rehabilitation
• Mental health treatment
Your premium depends on factors like your age, health, occupation, and the level of cover you choose. Most policies offer different levels of cover, from basic to comprehensive, allowing you to tailor the policy to your needs and budget.
Questions to ask yourself regarding private medical insurance
Just ask yourself:👉 Are you concerned about NHS waiting times for treatment?
👉 Would you prefer to choose your own consultant and hospital?
👉 Do you want faster access to diagnostic tests and scans?
👉 Would you like private hospital accommodation and better food?
👉 Do you want to avoid the stress of NHS waiting lists?
Many people don't realise that private medical insurance is more affordable than they think, especially when you consider the value of faster treatment and better facilities. A great insurance policy can provide peace of mind and ensure you receive the care you need when you need it.
Benefits offered by private medical insurance
Private medical insurance provides numerous benefits that can significantly improve your healthcare experience and outcomes:Faster Access to Treatment
One of the biggest advantages is avoiding NHS waiting lists. While the NHS provides excellent care, waiting times can be lengthy. With private medical insurance, you can often receive treatment within days or weeks rather than months.
Choice of Consultant and Hospital
You can choose your preferred consultant and hospital, giving you more control over your healthcare journey. This is particularly important for complex treatments where you want a specific specialist.
Better Facilities and Accommodation
Private hospitals typically offer superior facilities, including private rooms, better food, and more comfortable surroundings. This can make your recovery more pleasant and potentially faster.
Advanced Treatments
Private medical insurance often covers treatments and medications not available on the NHS, giving you access to the latest medical advances and technologies.
Mental Health Support
Many policies include comprehensive mental health coverage, providing faster access to therapy and psychiatric care when needed.
Tax Benefits for Business Owners
If you're self-employed or a business owner, private medical insurance premiums can be tax-deductible, making it a cost-effective way to protect your health and your business.
Peace of Mind
Knowing you have access to private healthcare when you need it provides invaluable peace of mind, especially for those with ongoing health conditions or concerns about NHS capacity.
Private medical insurance is particularly valuable for those who want to take control of their healthcare journey and ensure they receive the best possible treatment when they need it most.
Important Fact!
We can look at a more suitable option mid-term!
Why is it important to get private medical insurance early?
👉 Many people are very thankful that they had their private medical insurance cover in place before running into some serious health issues. Private medical insurance is as important as life insurance for protecting your family's finances.👉 We insure our cars, houses, and even our phones! Yet our health is the most precious thing we have.
Easily one of the most important insurance purchases an individual or family can make in their lifetime, the decision to buy private medical insurance can be made much simpler with the help of FCA-authorised advisers. They are the specialists who do the searching and analysis helping people choose between various types of private medical insurance policies available in the market, including different levels of cover and policy types most suitable to the client's individual circumstances.
It certainly won't do any harm if you speak with one of our experienced insurance experts who are passionate about advising people on financial matters related to private medical insurance and are keen to provide you with a free consultation.
You can discuss with them in detail what affordable private medical insurance plan for the necessary peace of mind they would recommend! WeCovr works with some of the best advisers in the market.
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