Step by Step Guide on How to Get Prior Authorization

To get prior authorization, you need to start by contacting your healthcare provider. They will guide you through the process and help determine if you need prior authorization.

Your healthcare provider will then submit a prior authorization request to your insurance company. This request typically includes a detailed description of your medical treatment and the estimated costs.

You can also check your insurance policy to see if prior authorization is required for specific treatments. This information is usually outlined in your policy's coverage section.

Once you've initiated the process, it may take several days or weeks for your insurance company to review and approve your request.

For another approach, see: United Healthcare Wegovy Prior Authorization

Prior authorization is a process used by insurance companies to ensure that patients are receiving medically necessary treatments.

Insurance companies use a prior authorization process to review medical treatment requests and ensure they meet certain criteria.

The goal of prior authorization is to prevent unnecessary or excessive treatment.

If this caught your attention, see: Prior Authorization Process Flow Chart

According to the Centers for Medicare and Medicaid Services, prior authorization helps to reduce healthcare costs by 15% to 20%.

Patients may need to provide detailed medical information to support their treatment requests.

Insurance companies often use a specific set of criteria to determine whether a treatment is medically necessary.

Before you even start the prior authorization process, it's essential to review the policy and determine if a code or service requires prior authorization. HCA's authorization services don't consider National Correct Coding Initiative (NCCI) guidelines, so make sure your office checks those prior to submission.

You can also review the clinical guidelines used by the reviewers to base their decisions. This can give you an idea of what information you'll need to submit to increase the chances of approval. If the guidelines are online, ask your health plan or benefits management company to share them with you.

To submit a request that's easy for the reviewer to approve, make sure you include clinical information that shows you've met the guidelines for the test, service, or drug you're requesting. This includes explaining any exceptions or special circumstances.

Expedited prior authorization (EPA) is a process designed to eliminate the need for written requests for prior authorization for selected services/items.

Some health insurance companies have EPA processes in place. For example, UnitedHealthcare, Cigna, and Aetna all take about 30 days to process a PA request, and they require a DME to be involved.

If you're eligible for EPA, you can skip the written request process. But, not all services or items qualify for EPA.

You can check if your health insurance company offers EPA and which services qualify by downloading their EPA inventory. For pharmacy POS expedited authorization (EA) codes and guidelines, check the Prescription Drug Program Expedited Authorization List on the program provider guides webpage.

Here are some health insurance companies that take a relatively short time to process PA requests: Blue Cross Blue Shield of Massachusetts takes about 3-5 business days, Harvard Pilgrim Health Care takes about 3 days, and Tufts Health Plan also takes about 3-5 business days.

Here's an interesting read: Health Plans Inc Prior Authorization

You can find a list of prescriptions that might need a PA request in the pharmacy benefit section of your health insurance plan, which is called a formulary or preferred medication list.

Prescriptions for non-preferred drugs are typically subject to prior authorization. To find out which drugs are preferred, check the Preferred Drug List (PDL) on your health insurance plan.

Prescriptions for preferred drugs in certain classes may also require prior authorization, as indicated in the Prior Authorization Clinical Guidelines. These classes include Beta Blockers, VMAT2 Inhibitors, and others.

If you're prescribed a drug not included in the PDL, it may require prior authorization as well. Check the Prior Authorization Clinical Guidelines for the specific drug or therapeutic class.

Prescriptions that exceed quantity limits, daily dose limits, or duration of therapy limits will require prior authorization. You can find the list of drugs subject to these limits on your health insurance plan.

A different take: Check Prior Authorization Status Blue Cross Blue Shield

Some prescriptions may require prior authorization if they have an FDA-approved generic equivalent available for substitution. However, if the brand name drug is designated as preferred on the PDL, it may not require prior authorization.

Prescriptions for beneficiaries of certain ages may require prior authorization due to age restrictions. Check the Prior Authorization Clinical Guidelines for the specific drug or class of drugs.

If you're prescribed a drug with the same mechanism of action as another drug you recently received, it may require prior authorization due to therapeutic duplication.

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To prepare for prior authorization, you'll need to gather some basic information. The name and Medical Assistance ID number (also known as the ACCESS card number) of the beneficiary are required.

You'll also need to provide the name and phone number of the contact person at the prescriber's office. This is usually the person who will be handling the prior authorization request.

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The prescriber's specialty or field of practice should also be included. This will help the reviewer understand the context of the request.

The prescriber's office address, phone number, and fax number are also necessary. Make sure to double-check these details to avoid any delays.

The prescriber's state license number and NPI number are also required. These are standard pieces of information that are usually easily obtainable.

The specifics of the prescription, including the drug name, strength, and formulation, must be provided. This will help the reviewer understand what is being requested.

A list of the required information includes:

To initiate the prior authorization process, the prescribing provider must start the request. This can be done by calling the Pharmacy Services call center at 1-800-537-8862.

Pharmacies may also call the Pharmacy Services call center to request an override for early refill denials. The call center is available Monday through Friday from 8 AM to 4:30 PM.

To initiate a request by phone, the Pharmacy Services call center accepts calls between 8 AM and 4:30 PM Monday through Friday. Clinical documentation supporting the medical necessity of the prescription must be submitted to the Department for all prior authorization requests.

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To initiate a prior authorization request, the prescribing provider is the one who must take the lead. This applies to all requests, except for early refill requests, which have a different process.

Pharmacies can't initiate a request for prior authorization on their own, but they can contact the Pharmacy Services call center for help. The phone number to call is 1-800-537-8862.

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You can initiate a prior authorization request by phone, which is a convenient option if you need to get a prescription approved quickly. The Pharmacy Services call center is available to take your call at 1-800-537-8862.

The call center is open Monday through Friday from 8 AM to 4:30 PM, so be sure to call within these hours to get assistance. You can also ask questions or get help with your request during this time.

To initiate a request by phone, you'll need to provide clinical documentation supporting the medical necessity of the prescription. This documentation should be faxed to 717-265-8289 after you've spoken with the Pharmacy Services coordinator.

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You can initiate a prior authorization request by fax, which is a good option if your prescribing provider prefers this method. To do so, you'll need to download the prior authorization fax form from the Pharmacy Services Prior Authorization Fax Forms website.

The fax form can also be requested by calling the Pharmacy Services call center at 1-800-537-8862. They'll send the form to your office.

You'll need to submit the completed, signed, and dated fax form, along with the required supporting clinical documentation of medical necessity, to the fax number 1-866-327-0191. This fax number is also printed on the top of each prior authorization fax form.

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To complete the prior authorization application, you'll need to find and complete the necessary forms. There are two main forms required: the General Information for Authorization (form 13-835) and the Pharmacy Information Authorization (form 13-835A) for drugs submitted through the pharmacy point of sale system.

For another approach, see: Blue Cross Blue Shield of Tn Prior Authorization Forms

Each individual service or item may require additional forms, so be sure to check the list on the Forms and publications webpage.

To initiate the prior authorization process, you'll need to submit the required forms. For general PA requests, you'll need a barcode cover sheet.

You can submit the PA request by direct data entry or by fax, but be aware that submitting by mail is no longer an option.

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Following up on prior authorization can be a frustrating and time-consuming process, but it's essential to ensure that your treatment is approved.

You can follow up on your prior authorization request by calling the insurance company's customer service number, which is usually listed on their website or on your insurance card.

It's a good idea to have your request number and any relevant medical information handy when you call.

Be prepared to explain your medical condition and how the treatment will benefit you, and try to be patient and persistent when dealing with customer service representatives.

If you're not getting anywhere with the customer service team, you can also try contacting the medical review department directly, as they may be able to provide more detailed information about the status of your request.

For another approach, see: What Do You Get When You Cross?

Checking the status of a prior authorization can be a crucial step in ensuring that your medical or dental services are approved in a timely manner.

You can check the status of an authorization by using the ProviderOne system.

Checking the status through the interactive voice response (IVR) system is also an option, but this starts on slide 24 of the webinar presentation.

If you're looking for correspondence related to your authorization, you can retrieve it through the ProviderOne system as well.

Here are the steps to check the status of an authorization or retrieve correspondence:

After you've submitted a request for prior authorization, the Department will notify the prescribing provider by return telephone call or fax.

The notice will indicate whether the request is approved or denied, and it's always a good idea to follow up on the phone to confirm the decision.

The Department will also send a written notice of approval or denial to the prescribing provider and the beneficiary by mail, so be sure to keep an eye out for this letter.

This written notice will serve as a record of the decision, and it's a good idea to save it for your files.

The Department's notification process is designed to be efficient and timely, so you can expect to hear back from them soon after submitting your request.

You can appeal a denied prior authorization request, and you have 30 days from the date of the notice to submit your appeal in writing to the address listed on the notice.

If you've already been receiving the denied medication and you act quickly, you can get a temporary approval until a decision is made on your appeal. You just need to hand-deliver or postmark your appeal within 10 days of the notice.

You have the right to know why your prior authorization request was denied, and you can ask the medical management company for more information. They might use jargon, but you can ask them to explain it in plain English.

If you can fix the problem that caused the denial, it's often easier to just submit a new request rather than appealing the original denial. This is especially true if you can get documentation to support your new request.

The Affordable Care Act ensures your right to an internal and external appeals process, unless you have a grandfathered health plan. And if you do appeal, you might be surprised at how often the original denial is overturned and the prior authorization is approved.

Curious to learn more? Check out: Appeal Prior Authorization Denial