Your health plan says it needs “prior authorization” — now what?

Learn the next steps for getting covered for the treatments you need if your incurance asks for a prior authorization.  

Sick African American woman working from home office using laptop drinking hot beverage covered with blanket.
Sick African American woman working from home office using laptop drinking hot beverage covered with blanket.

Under the weather? No worries. Your health care provider can figure out the problem and get you started on the road to recovery, right?     

It could get a little complicated, due to something called prior authorization (PA). This is when your doctor must fill out a form explaining why you need a certain drug, procedure, device, or piece of medical equipment like a wheelchair. For example, they may have to say why knee surgery is a better choice for you than a less-expensive cortisone shot.    

This practice — also called pre-approval or prior approval — is common in all types of health plans. It’s a way for health plans to keep costs down while also making sure you don’t get treatments you don’t need. If the PA is approved, your plan will help pay your bill. If not, you’ll need to work with your doctor on what to do next. Unfortunately, when a PA is denied, it slows things down. About 94% of patients said it caused a delay in their care in one survey. And 33% said a PA harmed their health.  

PAs are no fun for you — or your doctor. Providers complete about 45 PAs per week. And they spend about 14 hours doing it. If you learn you need a PA, understanding how they work can help you get the right care and coverage. Here’s what you need to know.  

What is prior authorization? And why do I need it?  

A PA is a restriction or limit by your health plan. It’s put on certain medications, tests, and health services. It can also be put on procedures like surgery, a CAT scan, or an MRI. It requires your doctor to ask your health plan if they will cover the item, says Adria Gross. Gross is CEO of MedWise Insurance Advocacy in Monroe, New York.   

Here’s why it’s done. Before your plan pays for part or all a procedure or drug, they will want to make sure it’s something you really need. They’ll ask questions like:  

  • Is it medically necessary?  
  • Is there a less expensive option that might work just as well?  
  • Do you need to continue a treatment if you’ve been getting it for a while?  

The answers to these questions will help your plan decide if they want to approve the PA.  

What do I need to do?  

Start by checking your health plan policy. It will tell you who needs to get the authorization. That might be:  

  • You.  
  • The insured person. (For example, if you are covered under your partner’s plan.)   
  • Your provider or hospital.  

If it is your doctor or hospital, it’s always best to ask them in advance. “Make sure they have followed through and received the authorization,” Gross says. “If it’s not completed prior to your procedure, you will not be covered. It is also very difficult to try to reverse the denial.” 

What if I need my medicine or treatment quickly?  

“You might need to call your insurance company 3 to 4 times a day to force them to finalize the request,” says Gross. If they do not respond? Reach out to your state’s Department of Insurance. Or call the Attorney General’s office for help.  

What if my prior authorization is denied?   

Talk to your provider right away. Ask them to help you appeal the case, says Gross. “Many times, the insurance carrier is going to ask for medical records. And your doctor needs to prove the reason why this is medically necessary,” says Gross.  

What else can I do to help move things along?  

Stay up to date on the approval status. You can usually check it on your health plan website, says Gross. If not, call your plan directly.  

A few more things to remember   

First, if your health plan gives you prior authorization, they might not pay 100% of the costs. You’ll still have to pay your share. That means you’ll need to pay: 

  • A deductible if you have one and haven’t met it yet.  
  • Any co-payments.  
  • Coinsurance if you have it.  

Also, some prior authorizations need to be renewed. That’s often true if you’re using a medication or treatment long term. The renewal usually works the same way as the first time. But your plan may also want proof that the medication or treatment helped your condition in the past. 

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