Prior authorisation (autorización previa) and how it works

Key rules

• No approval, no cover: If you have a procedure that needs approval without getting it first, the insurer can refuse to pay and you may owe the whole cost.
• Check your policy: The list of procedures needing approval differs by insurer, so read your policy conditions before booking.
• Validity: An approved authorisation is usually valid for around 30 to 90 days.
• Emergencies: Emergency care needs no prior approval, but tell your insurer about an admission within 24 to 48 hours, or the period in your policy.
• Complaints: The insurer's customer service department must answer a complaint within two months.

What prior authorisation means for you

Many tests and operations need your insurer's approval before you have them. If you skip it, the insurer can refuse to pay and you may face the whole bill. Get the approval first, then book.

Which procedures need it

Usually you do not need approval for:

• GP and specialist consultations
• basic blood tests
• X-rays
• ultrasounds

Usually you do need approval for:

• MRI, CT and PET scans, nuclear medicine and other high-cost diagnostics
• biopsies, and endoscopies in some cases
• scheduled hospital admissions and surgery, including day surgery
• rehabilitation or physiotherapy courses
• home oxygen therapy
• chemotherapy or radiotherapy
• genetic tests and sleep studies
• other high-cost treatments

The exact list differs by insurer and policy. Read the conditions of your policy before you book anything.

Who asks for it

Usually your doctor prescribes the test or procedure and the clinic or hospital asks the insurer, often through an online portal. For outpatient tests, though, you are often asked to request it yourself through the insurer's app, web area or phone line, using the doctor's request. For scheduled surgery, the hospital's admissions department normally handles it and you confirm. Ask the clinic at the start who will send it.

The steps

1. Your doctor writes a medical request (volante or petición médica). It states the test or procedure, the reason or diagnosis and the doctor's details. For surgery, add a medical report with the diagnosis and proposed procedure. A budget is sometimes needed too.
2. The request goes to the insurer through the clinic's portal. If it is down to you, send a photo of it through the app, or use the web area or phone. Some insurers also accept email or a visit to their office.
3. The insurer checks coverage, waiting periods and pre-existing exclusions. It may ask for more reports.
4. The insurer sends an authorisation number or document by app, SMS or email, or directly to the centre.
5. You book the test and take the authorisation, your insurance card and ID to the centre.

An approved authorisation is usually valid for around 30 to 90 days, so book the test or procedure within that window.

How long it takes

Routine tests such as an MRI or CT are often approved within minutes or a few hours through an app or portal, and typically within 24 to 48 hours at most. Scheduled surgery or admission usually takes one to several working days. It can take longer if the insurer asks for more medical reports.

Emergencies

Emergencies do not need approval first. If you are admitted through emergency care, tell the insurer within the period in your policy, typically 24 to 48 hours.

If you are refused

A refusal is not always the end. Do this:

1. Ask the insurer for the written reason and the clause it relied on.
2. Ask your treating doctor for a fuller medical report and send a new request. Some policies also offer a medical second review.
3. If that fails, complain to the insurer's customer service department (Servicio de Atención al Cliente). It must answer within two months.
4. If it rejects the complaint or does not answer, complain to the insurance regulator, the Dirección General de Seguros y Fondos de Pensiones.

Your policy may also provide for private mediation or arbitration. The civil courts are always an option. A lawyer or a consumer association can help.

Clauses that limit your rights must be clear and specifically accepted by you. If a refusal rests on a vague clause, say so in your complaint.

This page covers private insurance only. It does not apply to the public system.

Timeline and deadlines

• Get the medical request from your doctor: before you book anything

• Send the request to your insurer through the clinic's portal, the app, the web area or by phone: as soon as you have the request

• Wait for approval of scheduled surgery or a hospital admission: one to several working days, longer if more reports are requested

• If refused, complain to the insurer's customer service department: after a refusal and a new request fails

• Expect the customer service department's answer: within two months

• Complain to the insurance regulator if the complaint is rejected or unanswered: after the two months, or after a rejection

Documents you need

• Medical request (volante or petición médica) from your doctor, stating the test or procedure, the reason or diagnosis and the doctor's details.

• Medical report from the treating doctor with the diagnosis and proposed procedure, for surgery. A budget from the hospital is sometimes added.

• Authorisation number or document from your insurer, sent by app, SMS, email or directly to the centre. Take it to your appointment.

• Insurance card and ID to show at the centre when you go for the test or procedure.

• Written reason for the refusal, with the clause the insurer relied on, if your request is refused. Ask the insurer for it.

• Fuller medical report from your treating doctor to support a new request after a refusal.

Checklist

• Check your policy conditions for the procedures that need prior authorisation.

• Ask your doctor for a written medical request stating the test or procedure and the reason.

• Find out whether the clinic or hospital sends the request or you must send it yourself.

• Get the authorisation number or document before you book.

What to watch out for

• Treatment without authorisation can leave you with the whole bill: If a procedure that needs authorisation is done without it, the insurer can refuse to cover it and you pay the full cost. Get the authorisation number before you book surgery, an admission, an MRI, CT or PET scan. Check your policy for the list. Emergencies are normally exempt, but tell the insurer afterwards.

• A refusal is not always final: The insurer may refuse a request, and if you do nothing you may end up paying or going without care. Ask for the written reason and the clause used, then send a new request with a fuller report from your doctor. If that fails, complain to the insurer's customer service department, then to the insurance regulator (the DGSFP). A consumer association can help.

• Policy clauses that limit your rights must be clear: A clause that restricts your rights only counts if it is clear and you specifically accepted it. Read the authorisation and complaint clauses in your contract and ask the insurer to point out the ones you signed.

Frequently asked questions

Do I need prior authorisation for a GP or specialist visit?

No, GP and specialist consultations usually need no prior authorisation under a private policy. The same normally goes for basic blood tests, X-rays and ultrasounds. Scans such as MRI or CT are different, so ask your insurer before booking.

Can I ask for authorisation myself if the clinic does not?

Yes, you can usually request it yourself through the insurer's app, web area or phone line, using the doctor's medical request. Many insurers accept a photo of the request in the app.

What if I go to the emergency room without authorisation?

Emergencies do not need prior authorisation, so you can go straight in.