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Prior authorization is a process where insurers decide if a medication or treatment will be covered. It helps manage resources and control costs by preventing unnecessary or ineffective treatments, tests, or procedures that may not provide enough benefit to the policyholder to justify their expense.
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Have you ever arrived at a pharmacy to collect your prescription, only to be informed that it requires prior authorization? Or perhaps you’ve faced the need for prior authorization before undergoing a medical procedure, such as a knee replacement.
It’s natural to wonder why a prescription from your healthcare provider requires more than just health insurance coverage. In this Pacific Prime article, we clarify the concept of insurance prior authorization so you can navigate the process with confidence.
Explaining Prior Authorization
Prior authorization is the process doctors must go through to request that certain medical treatment, such as an MRI or surgery, be covered by medical insurance companies. Prior authorization goes by many names, including preauthorization insurance (or preauthorization for short) and prior approval.
Prior authorization is quite common, and most doctors state that it is even overused. Where prior authorization was originally used for brand-new drugs or procedures, it has become more widespread.
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How to Know When Prior Authorization is Required
Prior authorization is often necessary for medications and services that are either costly or lacking in safety and efficacy data, such as:
- Immunotherapy
- Chemotherapy
- Newer brand-name drugs
- High-risk invasive procedures (e.g. spine surgery)
- Aesthetic/cosmetic procedures
With more costly biological drugs for various conditions entering the market, prior authorization is becoming less of an exception and more of a normality for many policyholders.
Each insurance policy has its own prior authorization list. Some treatments may require approval under one plan but not another. The list might be available online, but it’s often hard to find or understand. These lists are designed for insurance providers and billing specialists, not patients.
Policyholders are often unaware they need prior authorization until they’re informed they must pay out of pocket due to a lack of coverage. This can lead to unexpected expenses, making it essential to check your policy and stay informed about any treatments that may require prior approval.
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How Long Does Prior Authorization Takes for Medication
The time it takes for prior authorization approval can vary depending on the insurer and medication. On average, it may take a few days to two weeks. For urgent cases, such as life-threatening conditions, the process may be expedited, but standard requests typically take longer.
To avoid delays, maintain communication with your healthcare provider and insurer. Your provider may need to submit extra documentation, which can impact the approval timeline. Follow up with your insurer regularly to ensure the process runs smoothly and to address any potential issues promptly.
How to Get Prior Authorization
Your doctor or their office staff will fill out and submit all paperwork related to prior authorization. If you are denied your medication or other care because your insurer requires prior authorization, contact your healthcare provider right away.
If you choose to receive care from a doctor or healthcare professional who is outside your health insurance network, you may be required to submit prior authorization forms yourself.
If your insurer requires health information from you as part of your prior authorization for a medical service or if you must submit the forms yourself, there are some steps that you’ll have to follow.
Talk to Your Insurance Provider
First, get in touch with your insurer’s office, and speak to a designated individual who handles prior authorization requests. Once you know who to speak to, find out what information you have to provide to proceed.
Submit Your Paperwork
Most often your doctor will complete your prior authorization work. If you must provide the information yourself, complete prior authorization forms, which your insurer will use to process your request. These forms require personal details and medical information about your treatment.
Filling out every section correctly can help prevent delays and ensure a smoother approval process. Providing accurate information is crucial, as errors or missing details may cause delays or denials. A mistake could require you to resubmit the form and prolong approval.
Double-check all entries before submission to avoid setbacks and ensure your request is processed quickly.
Keep a Record
It’s highly advisable to maintain a record of everything as you’re collecting and filing out the paperwork so you can easily refer back to it if there are any issues. What’s more, it can be helpful to keep records of your approved prior authorizations for future requests.
Even though your insurer’s office will assist you in staying up to date, setting your own reminders can help you stay on top of due dates. Staying proactive can prevent unexpected coverage issues and delays, ensuring you receive necessary treatments without disruptions.
What to Do if Your Prior Authorization Request is Denied
It’s important to discuss with your doctor what you’ll do if your prior authorization request is denied by your insurance provider. The first step following a denied request is to determine why.
If your doctor provided the prior authorization request, he or she will likely resubmit their claim and provide other information that will help insurers approve the requested treatment.
If you filled out the prior authorization paperwork and you’re sure that all the information you provided is correct, it’s worth finding out if there is anything else you can add to help justify your case.
Appeals Process for Denied Prior Authorizations
Prior authorizations, including appeals, are the responsibility of your doctor: your doctor wants you to get approval quickly and he or she spends extensive time seeking prior authorizations. If your prior authorization is denied, don’t lose hope. Most insurers offer an appeals process.
If you have selected to receive care outside your network and must fill out your prior authorization request yourself, the first step in seeking an appeal is understanding why the authorization was denied. This can be due to insufficient medical justification, incorrect forms, or other reasons.
Once you have this information, work with your healthcare provider to gather any additional supporting documentation. This might include medical records, test results, or detailed notes from your doctor outlining why the prescribed medication is necessary.
After submitting the appeal, insurers are generally required to review the new information and respond within a set time frame.
If your appeal is unsuccessful, you can request a second review or explore other methods of escalating the decision. Knowing how to navigate the appeals process is crucial, as it can significantly increase your chances of having the authorization reversed.
The Impact of Prior Authorization on Access to Medical Treatment
Prior authorization can sometimes delay access to necessary medications or treatment. For patients who require urgent treatment, these delays can be frustrating for them and their doctors.
If your doctor fills out your prior authorization request, rest assured that they are the expert and know best how to help you get the treatment you need. They likely also feel the frustration of delays, and they will be your advocate in this process.
If you’re facing a delay in getting approval for your prior authorization that you requested on your own, it’s essential to stay proactive. Contact your insurer to check the status of the prior authorization request and inquire if there’s anything you can do to expedite the process.
You may also want to ask if your healthcare provider can provide additional documentation to support the urgency of your case. In some situations, if the medication or procedure is time-sensitive, the insurer may speed up the approval or offer an alternative solution.
Get Expert Insurance Advice from Pacific Prime
Different health insurance plans have different rules regarding prior authorization. Doctors will likely do the work of prior authorization for you, but if you must speak directly to your insurance provider and seek help from a medical professional.
If you’re looking for international health insurance, individual health insurance, or other insurance plans, we’re here to help. As a global health insurance brokerage and employee benefits specialist with 20+ years of experience, Pacific Prime is your one-stop source for all things insurance.
Living by our motto of “simplifying insurance,” our insurance experts are available to answer your questions or help you find a suitable plan for your needs and budget.
Contact us to find out about your health insurance options or to receive a free plan comparison today!
Frequently Asked Questions
What is prior authorization in health insurance?
Prior authorization is a process where your health insurer requires approval before you receive certain medical services or medications to ensure they are medically necessary and cost-effective.
Why do insurers require prior authorization?
Insurers use prior authorization to manage costs and prevent unnecessary treatments by evaluating the necessity and efficacy of specific services or medications before approving coverage.
What should I do if my prior authorization request is denied?
Your doctor will most likely handle all prior authorization paperwork, including appeals. If the request is denied, he or she will review the denial letter to understand the reasons, gather supporting documentation, and follow your insurer’s appeal process to contest the decision.
After obtaining his Bachelor’s Degree in Social Sciences, International Relations from Mahidol University International College, Veerabhatr has forged his career as a content writer in the travel, lifestyle, and real estate industries, writing in both English and Thai. He now continues to hone his skills as a writer at Pacific Prime, looking to engage and educate the audience by simplifying insurance.
Writer by day, and a DJ by night, Veerabhatr is a staunch music lover, and listens to all spectrums of genres available. He also loves to drink beer (moderately), eat all types of food, go to the beach, and learn about different cultures across the globe. He is also a die-hard fan of football and motorsports.
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