What you need to know about prior authorization

Imagine this: You drop off a prescription at the pharmacy, swing back 30 minutes later to pick it up, and the pharmacist says that they need “prior authorization” before they can fill it. 

Although frustrating, this process helps your insurance company ensure that any care you receive is cost-effective and backed by the latest medical evidence. 

“I counsel patients to take the wheel and get into the driver’s seat,” says Georganne Vartorella, M.D., a patient advocate based in Lakewood, Ohio. “You’ve really got to get proactive to optimize your health care.” 

To do just that, here’s what you need to know about navigating prior authorization.

Expect a Thorough Review of Your Request

Prior authorization is a decision made by your health insurer about whether a given health service, treatment, prescription drug, or piece of medical equipment is needed, given your condition and medical history. These considerations are usually for treatments or prescriptions that are conditional, and not explicitly covered by your plan.

“Your insurance company is going to want to make sure whatever you are doing is medically necessary and, if you’re trying to go out-of-network, that there’s not an existing provider in your network that you can see,” explains Caitlin Donovan, director of outreach and public affairs for the National Patient Advocate Foundation.

If your health insurance plan requires prior authorization for a treatment or prescription recommended by your physician, they will need to submit a prior authorization request to your insurer. A nurse or physician at your insurer will review the submitted materials—including your medical history and why the recommended care is needed—and consult policy guidelines to make an initial decision on whether to authorize treatment. 

At this point, the reviewer will either inform the provider (and sometimes the patient) that the treatment has been authorized or, if they cannot approve the request, they will contact the insurer’s medical director. The medical director makes the final decision and, if denied, will explain to your physician why the request was denied.

The Prior-Authorization Process Takes Up to 15 Days

In most cases, insurers respond to preauthorization requests within 15 days, but it varies greatly by state. However, the clock starts when they receive the request from your doctor. If the process is taking longer than expected, or if you are in a hurry for treatment, you can contact your physician’s office and ask if the prior authorization request has been sent to your insurer.

You Won’t Have to Wait If It’s an Emergency

If your physician believes that the treatment is needed right away, they can submit an urgent request for prior authorization. These requests receive responses within 72 hours, enabling you to potentially get treatment much faster.

There May Be Alternatives That Don’t Require Prior Authorization

It’s your doctor’s job to find the best possible treatment plan for you––not necessarily what your plan covers, doesn’t cover, or requires prior authorization. Try to find out if a treatment you’re eyeing is covered before you leave the doctor’s office. You can typically get these details on coverage by calling your health care plan directly. Many health care plans also have a list of covered services online. 

If you find that a treatment will require prior authorization, it may be worth talking to your physician then and there about appropriate alternatives that the plan will definitely cover.

You Can Always File an Appeal

If your prior authorization request is denied, contact customer service ASAP. If customer service isn’t able to meet your needs, you and your doctor can file a formal appeal with your insurer, stating your case as to why the treatment is medically necessary. You can find instructions for filing an appeal on the back of the denial letter. 

“Advocate for yourself,” says Donovan. “Many people give up too soon.” The prior authorization process often involves several steps, and it’s important to work closely with your provider and insurer to get the health care you need.