Prior authorization: What to do if your health insurer requires it
Have you ever entered a pharmacy hoping to pick up your prescriptions and been told that it requires prior authorization? Or perhaps had to obtain prior authorization before a medical procedure, such as a knee replacement. You may be wondering why having a prescription from a healthcare provider, or health insurance in general, isn’t enough. In this Pacific Prime article, we shed light on insurance prior authorization, so you no longer have to wonder.
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What does prior authorization mean?
If you’ve ever spoken to your insurance provider after finding out that your medical procedure is not covered, it likely left you questioning: what is a “precertification report” underwriting? Prior authorization goes by many names, including preauthorization insurance (or preauthorization for short) and prior approval. It’s also common for those who are more familiar with insurance jargon to refer to it as PA.
Whatever you choose to call it, prior authorization is a process by which insurers determine whether medication or a medical treatment/procedure will be covered. Essentially, prior authorization allows insurers to manage resources and control costs by preventing ineffectual or unnecessary treatments, tests, etc., which may not be beneficial enough to the policyholder to justify their costs.
Further reading: Your guide to buying prescription drugs online in the UK
When is prior authorization 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 lately, 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. It’s possible for some items to require prior authorization under one policy but not with another. While you may be able to find the list on the insurer’s website or somewhere online, it tends to be hard to locate or understand since it’s catered to insurance providers and medical billing specialists rather than patients. Policyholders are often unaware that they require prior authorization until they are informed that they must pay out of pocket since they lack coverage.
Further reading: Top 8 health insurance exclusions you must know about
How do you get prior authorization?
If you’re required to get prior authorization for a medical service, there are some steps that you’ll have to follow. Let’s take a closer look at the prior authorization process flow.
Talk to your insurance provider
The first thing you have to do is get in touch with your insurer’s office, where there’ll be a designated person who handles prior authorization requests. Once you know who to speak to, the next thing you have to find out is what you have to provide them with to proceed. You can also discuss the process in greater detail, including what to do if your prior authorization request is denied (see below for more information).
Submit your paperwork
You’ll likely have to fill out some prior authorization forms that your insurer’s office will use to submit the request, including your personal information and medical condition/needs. Be sure to fill out the entire form accurately, as failing to provide correct or complete information could delay the process or result in a denied request.
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.
What to do if your prior authorization request is denied
It’s important to discuss what you’ll do if your prior authorization request is denied with your insurance provider. The first step following a denied request is to determine why. Sometimes, it might just be a minute error that can be fixed quickly.
If you’re sure that all the information you provided is correct and all the paperwork has been filled out, it’s worth finding out if there is anything else you can add to help justify your case.
Get expert insurance advice from Pacific Prime
Different health insurance plans have different rules regarding prior authorization. While you can speak directly to your insurance provider, a reputable insurance broker can offer impartial advice and help you find solutions with your best interest at heart.
Looking for private health insurance, individual health insurance, or other insurance plans? As a global health insurance brokerage and employee benefits specialist with 20+ years of industry 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!
Jantra curates and reports on the results of Pacific Prime’s monthly newsletters, as well as manages Pacific Prime’s Deputy Global CEO’s LinkedIn posts. Complemented by her background in business writing, Jantra’s passion for health, insurance, and employee benefits helps her create engaging content - no matter how complex the subject is.
Growing up as a third-culture kid has given her a multicultural perspective that helps her relate to expats and their families while 8 years of working remotely have given her unique insight into hybrid work arrangements and enthusiasm for employee benefits.
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