How the prior authorization process works (2024)

When you’re dealing with a health issue, the last thing you need is a surprise bill for care you thought was covered. That’s why understanding the prior authorization process is key to your health care.

The prior authorization process can be explained like this: In some cases, your doctor will recommend a treatment plan that your insurance may not cover. This is when they need to get approval from your insurance provider to know if your plan will cover it. This approval process is called prior authorization, and getting one before you get care means the care is appropriate and can be covered by your health plan benefits. It’s important to note, however, that what you’ll pay depends on the details of your specific benefits and where you get the care.

To find out if a medication requires prior authorization, check your insurance plan’s drug formulary. If you’re a HealthPartners member you can check your drug coverage online. The requirements for other medical care and procedures, as well as medication administered by a provider or in a clinic or hospital (such as some injectable medications) can be found in your benefits documents and your plan’s coverage criteria. And if you’re not sure, you can always call Member Services.

Below you’ll learn why insurance companies have prior authorization requirements, how the process works and what to do if your claim is denied.

Why insurance companies rely on the prior authorization process

Your health insurance provider has many reasons for requiring the prior authorization process in certain situations. Their focus is on you getting the right, in-network evidence-based care when it’s medically necessary.

1. Evidence-based care and quality assurance

Every doctor isn’t an expert in every type of treatment or medicine on the market. This is why health plans have doctors, pharmacists and others whose job is to make sure they know the latest in new innovations or treatments. Most plans also tie their coverage criteria to clinical trial results that ensure the treatment is recommended for patients in the member’s situation. They review medical literature, professional society guidelines and more to ensure members are getting evidence-based, medically necessary care.

2. Affordability

There are many types of care that do the same thing for very different costs. For example, an expensive brand name prescription drug may be available as a generic. It provides the same therapy but costs you a fraction of the price. The prior authorization process makes sure you’re getting the recommended treatment at a more affordable cost when possible.

3. Ensure everyone has what they need

Going through the prior authorization process also helps insurance providers make sure that people who need certain medicines or treatments can get access to them, particularly if they are limited. For example, medicines that are designed to help people manage diabetes are sometimes used by people who do not have diabetes for other reasons. If those medicines are hard to get, the prior authorization process can help ensure the members that are using the medicine for its intended purpose are getting enough access to it.

4. No surprise bills

This process also means that you as the patient know how your treatment will be covered before you get it. When your insurance provider has evaluated your treatment plan as part of the prior authorization process, you’ll also have a better idea of what you can expect to pay. Once it’s approved, check your benefits to see what your portion of the bill will be and what the cost-sharing will be for your treatment. That’s more peace of mind for you.

How the prior authorization process works

When your doctor prescribes a new medicine, course of treatment or test, you may want to confirm if a prior authorization step from your insurance provider is required. You can check with your clinic’s financial services team or your insurance provider’s member services team to determine this. You can also review your plan’s benefit documents.

In most cases, your care team will submit the request to your insurance provider for prior authorization. Larger hospitals or clinics might have a prior authorization process specialist whose job is to know the rules and contact the insurance provider on your – and your doctor’s – behalf.

They will provide the necessary documentation and medical codes so your insurance provider knows what type of care you’re seeking and can evaluate it through the prior authorization process.

Who is responsible for the prior authorization process

If a prior authorization request needs to be submitted to your insurance company, you shouldn’t have to do much more. The task of initiating the prior authorization process usually falls to your doctor, clinic or hospital unless you’re seeing a provider who is not contracted with your health insurance company.

Nurses’ role in prior authorization

Nurses often play a vital role in the prior authorization process. Sometimes, clinics or hospitals have a designated “prior authorization nurse” who oversees obtaining all prior authorizations needed for patients in their care. In other cases, your doctor’s nurse might reach out to you with next steps and updates on your prior authorization request. Nurses are also usually your point of contact for communication between you, your doctor and your insurance company about your prior authorization request.

Certain medicines require prior authorization

You’ll need prior authorization from your insurance provider for some prescription medicines. One reason for this is that it ensures high-cost medicines are being prescribed in accordance with the medical evidence about how they work. It’s important to make sure that medicine is being used in the right ways by the members who will truly benefit from it.

Always call Member Services or check your plan’s formulary online to confirm if your medicine requires a prior authorization step. You’ll also find requirements for administering your medication if it needs to be given to you by a doctor. In some cases, certain types of injectable medications can only be administered by a doctor, and it may be more affordable to have this done at a clinic rather than a hospital. Your insurance plan can help you determine the best location to receive your medicine.

It’s important to check your formulary and coverage criteria each year to see if anything has changed, and before you enroll in a new plan to understand what requirements exist for your medications. HealthPartners notifies impacted members when formulary changes are made, so be sure to also review communications sent to you directly. If you’re a HealthPartners member, you can find the latest information about your prescription coverage online.

Prior authorization for specialists

If your primary care doctor refers you to an in-network specialist, that specialist may determine a course of care. In this case, the specialist would be responsible for the prior authorization process. An example of this could be a primary care doctor sending you to an orthopedic surgeon who says you need a knee replacement. Your orthopedic surgeon would then be responsible for getting any prior authorizations required for your care. The “ordering physician,” the person who is performing your treatment, is almost always in charge of prior authorizations.

Submitting a prior authorization request yourself

In rare cases, you may need to submit a prior authorization request yourself. If so, you’ll need documentation from your doctor providing your diagnosis and the medical billing codes associated with your care plan. You should also know the name of any specialists and other locations that you would be receiving care from for the procedure that you’re seeking authorization for.

HealthPartners members can start and review the status of prior authorization requests, access forms, and learn more about prior authorization requirements online.

How long you’ll have to wait for a prior authorization decision

For medical prior authorization requests, waiting a few days is typical, but it can take a couple of weeks if the case is complicated or there’s a lot of back and forth between your insurance company and your provider. If needed, these requests can be submitted with urgency, which will alert teams that they need to be reviewed quickly due to medical urgency.

Most prior authorization requests related to medication or pharmacy needs are processed within 24 hours.

Prior authorizations often expire

Once you’ve obtained a prior authorization approval from your insurance company, it’s important to start your course of treatment as quickly as you’re able to. Since your health can change quickly, your insurance company will set a time limit for how long your approved prior authorization request is valid. Depending on the type approved, it may be in effect for a certain number of weeks, months or visits. Most prior authorizations don’t last longer than 12 months.

Difference between prior authorization, precertification and predetermination

Prior authorization and precertification are terms that can be used interchangeably.

Predeterminations are not required for HealthPartners members, but some insurance providers may ask for them. They are another way to demonstrate your need for a procedure. Your care team might be asked for medical records or photos that show your treatment plan is medically necessary. Some insurance companies may recommend going through the predetermination process to ensure that your doctor is recommending the services based on standard medical necessity guidelines, but HealthPartners will have covered these issues in the normal prior authorization process.

But even with a predetermination, you may still need to make a formal prior authorization request, depending on your plan.

What to do if your prior authorization request is denied

If your prior authorization request is denied, it may be because there are alternative options that could save you money or have better outcomes. This could be a generic version of a medicine or a newer, less invasive procedure. It may also be because the care requested is not medically necessary or isn't covered by your health plan. For example, many insurers do not cover cosmetic procedures unless they’re medically necessary.

Talk to your doctor about any alternative treatment options recommended by your insurance company. There may be another option that is covered by your insurance and will have the same, or better, results. All insurance companies have a process to appeal if you want your request to be reconsidered. Or you can choose to pay for the treatment or medication yourself, without your insurance coverage applying.

Where to find HealthPartners cost and coverage information

Existing HealthPartners insurance members can find cost transparency information online.

For more on what’s covered and what might need prior authorization, take a look at HealthPartners coverage criteria or contact Member Services at the phone number on your insurance card.

How the prior authorization process works (2024)
Top Articles
Latest Posts
Article information

Author: Aron Pacocha

Last Updated:

Views: 6350

Rating: 4.8 / 5 (48 voted)

Reviews: 87% of readers found this page helpful

Author information

Name: Aron Pacocha

Birthday: 1999-08-12

Address: 3808 Moen Corner, Gorczanyport, FL 67364-2074

Phone: +393457723392

Job: Retail Consultant

Hobby: Jewelry making, Cooking, Gaming, Reading, Juggling, Cabaret, Origami

Introduction: My name is Aron Pacocha, I am a happy, tasty, innocent, proud, talented, courageous, magnificent person who loves writing and wants to share my knowledge and understanding with you.