Fundamentals Updated June 19, 2026

Prior Authorization vs. Precertification vs. Predetermination: What Each Term Means and Why It Decides Whether You Get Paid

Prior authorization, precertification, and predetermination are all pre-service review processes, but they differ in whether they are required and whether they bind the payer on payment. Knowing which one a given payer applies to a given test is essential to getting reimbursed.

A Word, Spelled Three Ways, With Three Different Stakes

A genetics lab submits a high-cost molecular panel. The ordering clinic swears the test was "approved." The claim comes back denied. What happened?

Often, the answer lives in the gap between three terms that sound like synonyms and are routinely used as if they were: prior authorization, precertification, and predetermination. They are all pre-service review processes. They are not the same thing, and the differences, especially whether the process was required and whether the payer's answer bound them on payment, determine whether a clean claim gets paid or written off.

For lab directors, oncology clinic owners, and revenue-cycle and market-access leaders, this is not vocabulary trivia. It is the difference between a reimbursable test and an avoidable loss.

Educational use only. This article is general information, not medical, legal, billing, or coding advice. Terminology, definitions, and policies vary by payer and plan and change over time, and the same word can mean different things at different payers. Nothing here guarantees coverage or payment. Always verify requirements with the specific payer and plan, and consult qualified professionals before acting. Use at your own risk.

The One Thing to Understand First: The Terms Are Inconsistent

Before any definitions, internalize this, because it is the most important and most overlooked point: the industry does not use these words consistently. Authoritative payer documents themselves treat the terms differently from one another.

Cigna states that precertification is "also called prior authorization." (Cigna) Aetna describes precertification as the utilization review process used to decide whether a requested service meets its clinical criteria for coverage, and uses "precertification" where other payers say "prior authorization." (Aetna) Several Blue Cross and Blue Shield plans have gone a step further and renamed "predetermination" entirely, now calling it recommended clinical review. (BCBS Oklahoma)

So treat the definitions below as the common, prevailing patterns, not universal law. The operative question is never "what does this word mean in general?" It is "what does this payer, on this plan, mean by the term it is using for this test today?"

Prior Authorization and Precertification: The Required, Payment-Conditioning Reviews

In most payer ecosystems, prior authorization and precertification describe the same kind of process: a payer requires the provider to obtain approval before a service, drug, or test is delivered, and that approval turns on a review of medical necessity against the payer's clinical criteria. (Cigna, Aetna)

Two features define this category:

It is required. When a payer mandates prior authorization or precertification for a service and the provider does not obtain it, the payer can deny the claim. Industry billing guidance is blunt: any service requiring prior authorization that is not authorized will be denied for payment, and if a patient completes a non-emergency test before approval, the payer can deny payment even if the test was clinically warranted. (PracticeSuite) For labs, this is the dreaded "no authorization on file" denial, which is frequently hard to reverse after the fact.

Its answer is advisory on medical necessity but not a blank check. Here is the nuance that trips up even experienced teams: an approved prior authorization is still not a guarantee of payment. Payers say so directly. Obtaining prior authorization, like checking eligibility, does not guarantee payment; benefits are determined when the claim is received and depend on the member's eligibility on the date of service, the terms of the coverage, network status, exclusions, limitations, deductibles, copays, and coinsurance. (BCBS Illinois) Approval clears the medical-necessity gate; it does not clear every other condition of payment. Coding, documentation, and post-service review can still derail a claim that carried a valid authorization number. (Integrity Billing)

Note the practical asymmetry: prior authorization is close to binding against the provider (skip it and you usually lose), while it is only partly binding on the payer (they approved necessity, not everything else).

Predetermination: The Voluntary, Advisory Preview

Predetermination is the odd one out, and the most frequently misunderstood.

In its prevailing form, predetermination, now often called recommended clinical review, is a voluntary written request by a provider or member to learn whether a proposed treatment or service would be covered under the plan before it is rendered. (BCBS Illinois) Multiple Blue Cross and Blue Shield plans state that submitting the request before services are rendered is optional, and that its purpose is to flag, in advance, situations where a service may not be covered. (BCBS Montana)

Two features define this category:

It is usually optional. Skipping a predetermination does not, by itself, trigger a no-authorization denial the way skipping a required prior authorization does. It is a planning and risk-reduction tool, not a gatekeeping requirement.

It is explicitly not a guarantee of payment. Payers are emphatic: a predetermination or recommended clinical review decision is not a guarantee of payment, and benefits are determined only once a claim is received, based on the member's eligibility and the terms of the contract applicable on the date of service. (BCBS Illinois) It can tell you coverage looks likely and confirm that medical-necessity criteria appear to be met; it cannot promise the dollars.

For diagnostics and genetic-testing labs, predetermination shows up constantly. In settings where coverage varies, a preauthorization or predetermination request, sometimes referred to collectively as a prior authorization request, is often completed before genetic testing begins, packaging the CPT and ICD-10 codes, ordering-provider details, and clinical documentation for the payer's review. (Genetics in Medicine) Whether that submission is required or advisory depends entirely on the payer and plan.

The Comparison at a Glance

Prior authorization Precertification Predetermination
Common definition Required pre-service approval based on medical-necessity review against payer criteria Often the same process; many payers say it is "also called" prior authorization Voluntary pre-service request to preview whether a service would be covered (often rebranded "recommended clinical review")
When it happens Before the service, drug, or test is delivered Before the service is delivered Before the service, by choice; submission is typically optional
Typically required? Yes, when the payer mandates it for that service Yes, when the payer mandates it Usually no; voluntary at most payers
Typically binding on payment? No. Approval is not a guarantee of payment; other conditions still apply No. Same caveat; precertification does not guarantee payment of all billed services No. Explicitly not a guarantee of payment
What it does Clears the medical-necessity gate in advance; produces an authorization number Confirms the service meets clinical/coverage criteria before delivery Previews likely coverage and helps estimate patient responsibility
What it does NOT do Guarantee final payment; eligibility, coding, network status, and exclusions still apply Guarantee payment of every billed service Require you to do anything, or guarantee a dollar will be paid
Cost of getting it wrong Missing a required PA often means an outright, hard-to-reverse denial Same as PA Treating an advisory preview as a payment promise invites a post-service surprise

Sources for the table: Cigna, Aetna, BCBS Illinois, BCBS Montana, PracticeSuite.

Why the Distinction Hits Lab and Oncology Revenue Hardest

Two failure modes follow directly from confusing these processes.

The first is treating a required precertification as optional. A molecular panel or a tumor biomarker assay runs, the lab assumes a predetermination-style "we'll find out when we bill" posture, and the payer issues a no-authorization denial. Because the service is already complete, retroactive authorization is often unavailable, and the lab eats the cost or chases a difficult appeal.

The second is treating an advisory predetermination as a payment guarantee. A lab sees "criteria met" language, performs the test, bills, and is then denied on eligibility, coding, or a post-service review, all of which the payer reserved the right to apply. The preview was real; the promise never existed.

Both errors share a root cause: assuming the word tells you the process. It does not. The same payer can require prior authorization for one CPT-coded test, offer only voluntary predetermination for another, and use precertification language for a third, and any of those can change when the payer updates its medical policy. For genetic testing specifically, requirements differ sharply: some plans require authorization before the specimen is even collected, while others perform no pre-service review and instead apply criteria retrospectively. (Genetics in Medicine)

What to Actually Do

  • Identify the process by payer, plan, and CPT code, not by the label. Confirm, per test, whether the payer requires approval or merely offers a voluntary review.
  • For required reviews, secure approval before service and capture the authorization number on the claim.
  • For approvals of any kind, remember they are not payment guarantees. Keep eligibility, coding, and documentation airtight, because those are the conditions an authorization does not satisfy.
  • Re-verify when policies change. A test that needed no authorization last quarter may need one now.

That last point is where the real operational burden lives. Knowing which process a given payer requires for a given test, and catching when that requirement changes, is exactly the kind of payer-rules logic that Converus tracks, so reimbursement teams aren't deciding which of three look-alike terms applies from memory.

Sources

Frequently Asked Questions

Is prior authorization the same as precertification?
Most major payers use the two terms interchangeably. Cigna, for example, states that precertification is also called prior authorization, and Aetna and other payers treat precertification as the utilization review process to determine whether a requested service meets clinical criteria for coverage. Both are typically pre-service approvals that condition payment on advance review of medical necessity. Because usage is payer-specific, always confirm what a given payer means by its term.
Is predetermination required before performing a test?
Usually not. Many payers describe predetermination, sometimes rebranded as recommended clinical review, as a voluntary, written request to find out whether a proposed service would be covered. Several Blue Cross and Blue Shield plans state explicitly that submitting the request before rendering services is optional. By contrast, when prior authorization or precertification is required and is not obtained, the payer can deny the claim outright.
Does an approved prior authorization guarantee payment?
No. Payers commonly state that obtaining prior authorization is not a guarantee of payment. Final benefits are determined when the claim is received and depend on factors such as the member's eligibility on the date of service, the terms of the plan, coding, and applicable exclusions and limitations. Approval addresses medical necessity, not every condition of payment.
Why does the difference between these terms matter for a lab?
Because the wrong assumption costs money. Treating a required precertification as if it were optional can produce a no-authorization denial that is difficult to reverse. Treating an advisory predetermination as a payment guarantee can leave a lab surprised by a post-service denial. Each test, payer, and plan can use a different process, and those requirements change over time.
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