Also Known As
Prior authorization is also known as precertification, predetermination, and pre-approval.
Your health plan uses prior authorization as a way to keep healthcare costs in check.
Ideally, the process should help prevent too much spending on unnecessary medical care.
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A pre-authorization requirement is a way ofrationing health care.
In the process of prior authorization, your insurer will double-check that certain criteria are met.
States have various rules on the books to regulate the prior authorization process for state-regulated health plans.
Medical Necessity
Beingmedically necessarymeans that you really do need the service or drug your provider is prescribing.
Theyre also checking to see to it that the service is not being duplicated.
For example, if you have lung cancer you might be seeing more than one specialist.
The procedure or drug should be the most economical treatment option for your condition.
For example, imagine that Drug C and Drug E both treat your condition.
Drug C is cheaper and Drug E is more expensive.
Some insurance companies require step therapy in these situations.
Benefits
Your insurance provider needs to confirm that ongoing or recurrent service is actually helping you.
In that case, your insurance plan might wonder if the PT is actually helping you.
The additional three months might be pre-authorized if youre making slow but measurable progress.
(Retro authorization is occasionally used after the fact in emergency situations, although this is rare.)
Medicare Advantage plans often do require prior authorization.
Health plans each have their own rules in terms of what services need prior authorization.
But some services will require prior authorization under one health plan and not under another.
If you needemergency medical care, most insurers do not require prior authorization.
In some cases, they may do the authorization process after you get care (retroactive).
A prior authorization form will include information about you, as well as your medical conditions and needs.
It’s very important that you fill out these forms completely and confirm that the information is accurate.
If there is information missing or wrong, it could delay your request or result in denied prior authorization.
Keep Track of Dates
You may have deadlines for providing information.
Your provider’s office will probably be working on a timeline to submit documents during the prior authorization process.
If yourprior authorization request is denied, the first step is to find out why.
If a simple error was the problem, it might be a quick fix.
For example, your provider might know of research that would be helpful to include.
Different health plans have different rules for when prior authorization is required.
If your insurer denies coverage, you’re free to ask them to reconsider.
Your providers office can let you know what steps you better take to appeal the decision.
American Medical Association.Prior authorization practice resources.
Blue Cross Blue Shield.Why do I need prior authorization for a prescription drug?.
Centers for Medicare and Medicaid Services.2024 Medicare Advantage and Part D Final Rule (CMS-4201-F).
Axios.States jump into fight over prior authorization requirements.
American Medical Association.2022 prior authorization state law chart.
