Your healthcare provider recommended a treatment or medicine. But insurance requires a prior authorization. If you find yourself wondering why this extra bit of red tape exists, you’re not alone. But a denial on a prior authorization doesn’t mean you’re stuck. Working with your provider to appeal a denial can help you get the care you need.
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A prior authorization (PA) is a type of permission a healthcare provider needs to get from your health insurance. If your insurance approves it, that means they’ll pay for the care your provider requested. PAs are also known as preauthorizations, precertifications or “prior auths.”
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If your provider treats you without a PA, your insurance may refuse to pay for your care. That would leave you responsible for the costs. Or if you can’t pay, your healthcare provider or their organization would end up footing the bill. That’s why they wait for PAs.
The main reason that insurance providers require PAs is to save money. PAs can do that in a few ways:
PAs can sometimes also protect you from potential harm. That can happen with:
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PAs have been around for years. Early on, they mainly applied to experimental drugs and treatments, which were often very expensive. But today, insurers use PAs for many treatments, including generic drugs and standard treatments.
Providers don’t need a PA if you need emergency care. But they might need a PA for the care you need after emergency treatment. Some states have laws that exclude specific events, like giving birth or your newborn staying in a neonatal intensive care unit (NICU).
Some states have laws that require insurers to issue “gold cards” to providers with high PA approval rates. Having a gold card means your provider has proven themselves and doesn’t need to submit PAs.
Because the laws vary from state to state, you may want to look up what your state laws say about PAs. You can also learn more about PAs and how they affect you from your insurance company. Some ways to do that include:
Getting an answer on a prior authorization can take time. How long you wait depends on a few factors.
The first factor is the type of care you need. If the care you need is urgent, most states’ laws say the insurance company has to respond within one to three days. If the care isn’t urgent, insurance companies have several days to respond. Some states set that as short as two days or as long as 15 days.
Many states have laws that also set time limits on appeals. For urgent/expedited cases, insurers usually have between two and three days to respond to an appeal. For nonurgent cases, it can be up to 30 days.
Depending on the law in your state, the deadline for your insurance company’s response can vary. Some states’ laws specify that the countdown to the deadline starts when your insurer has all the paperwork needed to make a decision. It’s a good idea to check your state’s laws and/or ask your insurance plan for more information about what you can expect.
Some key details you might want to know about include whether your state law says:
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Your healthcare provider or their staff, or pharmacy staff, are the ones who ask for a PA. Many electronic medical record systems can link with insurance company systems. Providers or medical/pharmacy staff check if a medicine or treatment needs a PA and then submit one, if necessary.
Insurance companies typically contact your healthcare provider first when denying a PA. Your provider can then tell you. Your insurer will also likely send you a letter by mail telling you about the denial.
If your insurance denies a PA, you aren’t out of options. Your provider can appeal the decision. They may ask you for more information or records related to your situation. Appealing and giving your insurance that information may be all it takes for your appeal to succeed. About 4 out of 5 appeals end up overturning an earlier PA denial.
If you have health insurance through your employer, you may also want to talk to someone in human resources (HR). They may be able to assist in appealing a denial. And you can also turn to your state’s department of insurance to file complaints or grievances, if necessary.
Depending on the law where you live, your insurance company might have to meet certain requirements when it comes to explaining PAs to you. That can include:
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Some examples of the documents you might ask for include:
Learning that you need prior authorization from your insurance can feel confusing. Insurance can be hard enough to understand under ideal circumstances. In stressful health-related situations, it might feel overwhelming.
But if you have questions, you don’t have to search for them alone. If you have questions about a PA, like appealing a denial or avoiding them altogether, ask your healthcare provider or one of their staff for guidance. They want to support you, and they’ll try to help you navigate this so you can get the care you need.
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