Prior authorization: What you need to know  (2024)

FAQs

What you need to know about prior authorization? ›

Prior Authorizations

Under medical and prescription drug plans, some treatments and medications may need approval from your health insurance carrier before you receive care. Prior authorization is usually required if you need a complex treatment or prescription. Coverage will not happen without it.

What to do if prior authorization is denied. The common reasons for an insurance company to deny a PA include procedures and medications not indicated for the diagnosis, off-label use of the medications, or generics available when a brand name is requested.

Examples of services that commonly require prior authorization before being approved include: Diagnostic imaging (such as MRIs, CTs, and PET scans) Durable medical equipment (such as wheelchairs) Rehabilitation (like physical or occupational therapy)

Level One: The initial phase begins with the doctor and patient contacting the payer to demonstrate that the requested treatment is medically necessary, and to request that the health plan re-evaluate the denial.

You or your doctor contact your insurance company and request that they reconsider the denial. Your doctor may also request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer insurance review” in order to challenge the decision.

Check prior authorization requirements before providing services or sending prescriptions to the pharmacy — Taking this step will help prevent delays to filling prescriptions, denials of claims and lost payments that can result from unmet prior authorization requirements.

Payment Authorization is a process through which the amount to be paid on a payment method is verified. In case of credit cards, authorization specifically involves contacting the payment system and blocking the required amount of funds against the credit card.

Of the 35.2 million prior authorization determinations, 33.2 million were fully favorable, meaning the requested item or service was covered in full. The remaining 2.0 million requests (6% of the total) were denied in full or in part in 2021.

What are the most common prior authorizations? ›

Genetic testing, specialty drugs and high-tech imaging are some of the most common treatments that require prior authorization, according to a Nov. 14 survey from AHIP.

Health insurance providers use Prior Authorization as a utilization management strategy which requires an evaluation of the medical necessity and cost-of-care implications of specific treatments, tests, and drugs given by medical care practitioners before administering them.

Pre-authorization can take a few minutes to several days, depending on the complexity of the procedure or service being requested. For example, some medical procedures may require extensive paperwork and review by an insurance provider before they are approved.

Screening colonoscopy procedures only require prior authorization for site of service medical necessity review if the service is planned at an outpatient hospital.

Prior authorization would be used to limit coverage in this situation to those patients where safety and appropriate use has been documented. A prior authorization request for an off-label indication requires documentation from the prescriber to confirm the use for which the product was prescribed.

Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.

Prior authorization can impact patient access to care by creating delays, healthcare providers report. In the AMA survey, 42 percent said their patients often see care access delays, and 37 percent said they sometimes do. These problems have been reported by other clinicians, too.