11/6/2024

While receiving medical care or picking up a prescription, you may have heard about something called prior authorization. Prior authorization requires your doctor or provider to obtain approval from your health plan before providing health care services or prescribing prescription drugs. 

Without prior authorization, your health plan may not pay for your treatment or medication. (Emergency care doesn’t need prior authorization.) 

Why do health plans require prior authorization? Prior authorization is a check that your plan covers the proposed care. It’s also a way the health plan can decide if the care is medically necessary, safe and cost effective. 

Medicare Part A and Part B generally do not require prior authorization. However, Medicare Advantage and Medicare prescription drug plans (Part D) may require prior authorization. 

What is medically necessary? A medically necessary service or prescription drug is one that’s needed to diagnose or treat an illness, injury, condition, disease, or its symptoms. It must meet accepted standards of medicine. To decide what’s medically necessary, your health plan must follow any state and federal laws that apply. You can review this NAIC guide on medical necessity to learn more. 

How do health plans decide what’s safe? To be considered safe, procedures, treatments and prescription drugs must meet the latest clinical standards and guidelines. They must avoid negative interactions between any drugs you’re already taking or treatments you’re receiving. 

What medications and services require prior authorization? Your health plan has a list of medications and services that typically require prior authorization. You can find the list in your plan documents, which may be sent to you and/or are available online. 

What if my health plan has concerns with a proposed treatment or medication? The health plan may deny the request, ask for more information, recommend another approach, or talk with your provider to agree on the most appropriate care plan. Your health plan might suggest other tests based on clinical guidelines before making a decision. 

Do I need prior authorization to continue a treatment I’m currently receiving? You may. Your health plan may require your provider to confirm that ongoing services or medications will continue to help you. 

How does the prior authorization process work? 

Your health care provider can make the prior authorization request. If your provider submits the request, they will send the required information to your health plan. You may need to fill out forms for your provider’s office. A prior authorization form will include information about you, your medical conditions, and your health care needs. It's important to fill out the form completely and accurately. Incomplete or incorrect information could delay your request or result in a denial. 

If you plan to submit the prior authorization request, ask your health plan how to complete it. Make sure you meet the deadlines your health plan gives you. Keep copies of all documents and communications sent and received. Note dates and the names and titles of people you speak with. You may need this information if the request is denied. Keep a record of approved prior authorizations in case you need to ask for another one in the future. 

How long do prior authorization decisions take? This depends on how urgently you need the care. If your need is urgent, you or your provider can ask for an expedited (or quick) review. State or federal rules may limit the time a health plan can take to make decisions. 

Could my health plan deny prior authorization because of cost? Yes, health plans may deny prior authorization when similar drugs or services are equally safe and effective but cost less. For example, a health plan may approve a drug only if you try a less expensive drug first and that drug isn’t effective or causes side effects. 

Can I appeal if I think my prior authorization request was incorrectly denied? Yes, you may appeal a health plan’s prior authorization decision. Before starting the appeal process, call your health plan to learn why prior authorization was denied. 

Check that all the requested information was received and correct. If a simple error, such as missing information, was the problem, correcting the error might be a quick fix. 

If all information is correct, and nothing is missing, you’ll need to partner with your provider’s office to start an appeal. Give the office the reason for the denial. Ask if there’s other information that could support the prior authorization request. If so, you or your provider can follow your health plan’s instructions to submit an appeal.