The first time your doctor gives you a prior authorization, you may be confused. Isn’t getting a prescription enough of a prior authorization? What does the insurance company mean by this term? But prior authorizations aren’t too hard to understand, and if you understand what they are, you’ll also understand how you can obtain one. Read on to find out more about how pre-authorizations work as part of your health care plan.
What are prior authorizations?
Prior authorizations (PA), sometimes known as a “pre-authorization”, is something your health insurance company requires from your doctor before it covers the costs of a specific medicine, medical device, or procedure. This often involves your doctor completing paperwork to explain to your insurance company why the medication you have been prescribed is “medically necessary” -- another insurance term. Your insurance company will have its own internal requirements that need to be met before it agrees to cover the specific item, treatment, or medication.
“Medically necessary” services, according to an insurance company, are defined as such if a doctor would normally provide those services to a patient in order to evaluate, diagnose, or treat an illness, injury, disease, or its symptoms. Medically necessary services are:
• In accordance with the generally accepted standards of medical practice • Clinically appropriate in terms of type, frequency, extent, site and duration • Considered effective for the patient’s illness, injury or disease • Not primarily for the convenience of the patient or doctor • Not more costly than alternative services that are at least as likely to produce equivalent therapeutic or diagnostic results for that patient’s illness, injury or disease.
You can see how in some cases, the doctor and the insurance company might disagree as to whether a treatment is effective, appropriate, cost-effective, or convenient. That is why the insurance company requires the doctor to submit this paperwork before it agrees to cover the treatment in question.
It’s important to note that each insurance plan is different. One health insurance plan may not require a PA for your particular treatment, while another plan -- even one from the same insurance company -- may. You need to check your insurance plan policy documents closely in order to understand if PAs are required and if so, under what circumstances.
PAs may also differ in the kind of paperwork required. For example, a pharmaceutical pre-authorization for a particular medicine may require the doctor to submit information different from a medical pre-authorization for a particular item.
How do I get prior authorization for a medication?
Check your insurance plan and formulary to see if any of your treatments require a PA. These may be found on the plan’s website, or the insurance company may have mailed you a hard copy.
If your treatment requires a PA, locate the process for submitting PAs and obtain copies of the forms. While this information may usually be found on the plan’s website, you can also call the member services number on the back of your insurance company.
It’s important to realize that it is your doctor’s office, and not you personally, that is responsible for submitting PAs for approval. You will have to work with your doctor, or whoever is on staff and designated to handle PAs, to make sure they have all the information they need.
Make sure the PA request is submitted according to your insurance plan’s guidelines and using the right form, completely filled out. Double-check that you meet all the plan’s requirements before the PA request is submitted.
Once the request is submitted, the insurance company will either approve or deny it. If approved, the insurance plan will cover the requested treatment. Be aware that the approval letter may include rules about how you obtain the treatment, such as a certain timeline in which you must order and receive the medication in order to be covered. Be careful to follow those terms.
If the request is denied, plan to appeal the decision.
Tips and tricks for obtaining a PA
Work together with your doctor’s office.
• Who at your doctor’s office deals with prior authorizations? Find out who this critical staff member is and work to establish a good rapport with them. This may help smooth the whole PA process over.
• Ask your doctor how other patients with similar medication requests got their insurance companies to approve their treatment. You may find fruitful answers for your own quest here.
• Ask the prior authorization staff member in your doctor’s office about the steps of the typical process. Those details may help you understand the next steps and likelihood of success for your own request.
• It’s likely your doctor’s office has its own approach it uses to show the medical necessity of a particular treatment. Work together to include information illustrating how the medication is medically necessary for managing your condition. You may want to include information on how a denied request may lead to not being able to comply with new treatment guidelines, having to pay for medication out-of-pocket, more expensive treatments or even emergency room visits. These points may help the insurance company see why it should cover the desired medication.
• Your doctor’s office will be able to help you navigate the appeals process, if the insurance company initially denies your request.
• Make sure the PA form is fully complete before it’s submitted. You would be surprised how many PA requests are denied because the form is either not completed accurately or not fully completed.
• Take notes when you are speaking to insurance representatives. Include the date, time, the number called, the representative name, and the outcome of the call. Your call or request may even have a special number assigned to it that you should note down as well. You want as many details as possible in case you need to follow up.
• Review the PA form before meeting with your doctor to make sure you know all the necessary criteria and info you need to complete that form. You may have medical information from another doctor, such as lab results, to support your request. Make sure to bring copies of that information with you as well.
• Consider supplementing the PA form with additional data or evidence. Some good pieces of data to add are lab results that meet the insurance criteria or peer-reviewed published articles that support your treatment request. You can also quote relevant information or clinical guidelines that support your request.
• Keep records of when your new PA expires. Remember to begin the process of getting a new PA at least one month in advance of the old one’s expiration so you don’t have any gaps in treatment.
• Start the PA process early in order to avoid a delay in medication.
• Know when your information needs to be submitted. Insurance companies often have strict deadlines for PAs.
• if your need is urgent or time-sensitive, you may be able to utilize an expedited approval process. You can find information on such processes, if your insurance company has them, by checking your plan documents, talking to a member services representative, or speaking to your doctor’s office staff.
• Insurance companies will occasionally authorize a short-term supply (a few days’ worth) of a prescription while a PA is in process. If you need a short-term supply, don’t hesitate to ask.
While getting and submitting PAs is usually the realm of the doctor’s office, it’s possible for you to take an active role in your health treatment plan and push for the treatment you and your doctor agree is needful.