Understanding Prior Authorization Services and Coverage

Prior authorization services can be a complex and time-consuming process, but understanding how they work can help you navigate the system more effectively. Prior authorization is a requirement for certain medical treatments, procedures, or prescriptions, and it's usually initiated by a healthcare provider.

Your insurance company will review the request to determine if it's covered and if there are any specific requirements that need to be met. This process can be lengthy, taking anywhere from a few days to several weeks.

In some cases, prior authorization may be required for specific medications, such as those used to treat chronic conditions like diabetes or rheumatoid arthritis.

Prior authorization services can be a complex and time-consuming process, but it's essential to understand what services require prior authorization to avoid unnecessary costs.

In general, services requiring prior authorization include inpatient care, hospital-based outpatient services, and procedures that require an assistant surgeon or anesthesiologist who is not in the health plan provider network.

Some specific services that require prior authorization include reconstructive surgery, outpatient cardiac and pulmonary rehabilitation, and non-emergent primary care services rendered by a non-plan network provider.

Here are some examples of services that require prior authorization:

The prior authorization process typically takes between 2 to 14 calendar days to complete, depending on the type of request.

Services that require prior authorization can be a bit overwhelming, but I'm here to break it down for you. Inpatient care and hospital-based outpatient services require prior authorization.

Some procedures that need prior authorization include those that require an assistant surgeon, co-surgeon, or anesthesiologist not in your health plan's provider network. These also include reconstructive surgery or other procedures that may be considered cosmetic.

Outpatient cardiac and pulmonary rehabilitation, as well as non-emergent primary care services rendered by a non-plan network provider, require prior authorization. Non-emergent services rendered by a non-Preferred Specialist provider also need prior authorization.

Other services that require prior authorization include home healthcare services, including home care agency visits, uterine monitoring, sleep studies, and hospice care. However, home visits billed as an E&M service are exempt from prior authorization.

Here's a list of services that require prior authorization, grouped by category:

It's worth noting that some services, like radiological services, hip surgeries, and genetic testing, require prior authorization before they can be provided at an outpatient location, except in cases of an emergency.

Public reporting is becoming a thing in the prior authorization world. Beginning March 31, 2026, insurers will be required to publicly report certain prior authorization metrics.

Insurers will need to reveal how often patient data is transferred electronically.

Starting January 1, 2025, prior authorization is required for Part B Step Therapy Program medications. This means that patients will need to meet certain requirements before receiving these medications.

For Part B Step Therapy Program medications, prior authorization is a necessary step. This is a change from previous requirements.

Insurers will be required to include information about prior authorization decisions in Patient Access, Provider Access, and Payer-to-Payer APIs. This is part of a larger effort to improve interoperability.

Prior authorization is required for Part B Step Therapy Program medications starting January 1, 2025. This means you'll need to get approval from Medicare before getting certain medications.

Medicare requires prior authorization for Part B Step Therapy Program medications starting January 1, 2025. This ensures that you're getting the most effective treatment for your condition.

The Part B Step Therapy Program requires prior authorization for certain medications starting January 1, 2025. This is a change from previous years, so be sure to check with Medicare for the most up-to-date information.

On Dec. 1, we won't require prior authorizations for the Texas Medicaid and Healthcare Partnership Children and Pregnant Women program services. This change aims to make it easier for those in need to access necessary care.

As of January 1, 2026, payers will be required to build and maintain a Fast Healthcare Interoperability Resources (FHIR) API that providers can use to determine if a prior authorization is required for a given item or service.

This API will allow providers to facilitate requests and indicate request statuses, making the prior authorization process more efficient and streamlined.

Payers will need to develop a digital operating model and advanced technology capabilities to support this new requirement, which will involve rapid shifts in organizational priorities.

Providers will use the FHIR API to determine if a prior authorization is required, making it easier to get the information they need to care for their patients.

Insurers will be required to include information about prior authorization decisions in Patient Access, Provider Access and Payer-to-Payer APIs, promoting greater transparency and interoperability.

The FHIR API will be a game-changer for the prior authorization process, enabling providers to get the information they need quickly and easily.

To achieve seamless prior authorization services, insurers must include information about prior authorization decisions in Patient Access, Provider Access, and Payer-to-Payer APIs.

This requires companies to maintain strategic partnerships with providers to arrange payer prior authorization rules and content within the provider's electronic health record-keeping.

Companies like PreCheck MyScript integrate directly within electronic medical records, allowing for easy pharmacy trial claims and real-time prescription coverage details.

Pharmacy digital tools can make a big difference in how smoothly your practice runs. PreCheck MyScript integrates directly within your EMR, allowing you to easily run a pharmacy trial claim and get real-time prescription coverage details.

Using digital tools can save you time and reduce errors. This integration enables you to quickly verify prescription coverage, which can be especially helpful during peak periods or when dealing with complex cases.

Interoperability requirements are crucial for seamless data exchange between different healthcare systems. This involves insurers including information about prior authorization decisions in Patient Access, Provider Access, and Payer-to-Payer APIs.

To achieve this, insurers must make a significant shift in their data sharing practices. This would enable healthcare providers to access patient information more efficiently.

Companies would need to maintain strategic partnerships with payers to ensure that payer prior authorization rules and content are integrated into provider workflow. This would require a high level of coordination and communication between different stakeholders.

By doing so, healthcare providers can have a more comprehensive view of patient information, which can lead to better care outcomes.

Providers should anticipate Prior Authorization needs well in advance when feasible. Be sure to submit all applicable clinical information supporting the reason for the request.

There are two ways to submit a Prior Authorization request: EZ-Net, which is the preferred and most efficient way, and FAX.

To use EZ-Net, you'll need login credentials, which you can learn more about on the EZ-Net page.

Prior Authorization requests may take some time to process, and providers should be prepared to wait for a response.

An authorization review can take between 2 to 3 business days to complete, after the doctor has submitted the request.

Decisions are made as expediently as possible, but the process may be slower due to a lack of sufficient clinical information or other factors.

If your request is denied, you'll receive a letter from Florida Blue explaining the decision and providing steps to appeal.

Prior authorization is a process that helps ensure you're getting the right care and that your procedure or medication will be covered. This is especially important for certain medical services that require approval before they can be provided.

If you need inpatient care or hospital-based outpatient services, you'll likely need prior authorization. The same goes for procedures that require an assistant surgeon or anesthesiologist who isn't part of your health plan's network.

Some specific medical services that require prior authorization include radiological services like CT scans, MRIs, and PET scans. Hip surgeries, such as revision or total hip arthroplasty, also require approval before they can be performed. Additionally, services like genetic testing, durable medical equipment, and assisted reproductive infertility treatments may need prior authorization.

Here are some examples of medical services that require prior authorization:

If you're trying to figure out which medical services are covered without needing prior authorization, it's actually pretty straightforward. Most office-based services and many freestanding Ambulatory Surgery Center services provided by primary care physicians and preferred specialists are covered without prior authorization required.

If you're seeing a specialist, it's worth noting that not all specialists are considered "preferred." If you're unsure, you can check with your insurance provider to see if they're part of the preferred network.

Services performed in a hospital setting, whether it's an inpatient or outpatient center, or even in a hospital-owned imaging center, do require prior authorization. This is a standard policy that applies to both EmblemHealth and Anthem plans.

Here are some key points to keep in mind:

Some medical services require prior authorization to ensure that clinically appropriate quality of care is provided. This means that your doctor needs to consult with the health plan's medical team before providing certain services.

EmblemHealth and Anthem plans, for example, require prior authorization for most hospital-based services, including inpatient care and hospital-based outpatient services. This includes services like reconstructive surgery and outpatient cardiac and pulmonary rehabilitation.

If you're a specialist, you'll need to check if you're a Preferred Specialist before providing services. Some services, like office-based services and freestanding Ambulatory Surgery Center (ASC) services, are covered without prior authorization.

Here are some examples of services that require prior authorization:

This list is not exhaustive, and you should always check with your health plan to confirm which services require prior authorization.

Medicare Advantage insurers denied 3.4 million prior authorization requests in 2022, which is 7.4% of the total determinations made that year.

The majority of these denials were adverse, meaning the request was denied in full. In each year, a smaller share of determinations were partially favorable, with only part of the request being approved.

Across most insurers, a small share of denied prior authorization requests were appealed, but Cigna stood out with a high rate of 50.4% of all denials being appealed.

In 2022, Medicare Advantage insurers varied significantly in their prior authorization practices. For example, Cigna had a much higher rate of appeals, with 50.4% of all denials appealed, compared to other insurers like Kaiser Permanente, which had a rate of just 3.5%.

The denial rate also varied across insurers, with CVS denying the highest share of prior authorization requests at 13.0% and Anthem denying the lowest share at 4.2%. This variation highlights the need for clarity and consistency in prior authorization policies.

A small share of denials were appealed across most insurers, but the exception was Cigna, where a much higher share of denials were appealed. The number of appeals per enrollee also varied, with Cigna having a rate more similar to other insurers despite its high appeal rate.

Most insurers that had more prior authorization requests per enrollee than average denied a smaller share of those requests than average, and vice versa. However, Centene was an exception, having both a relatively high number of prior authorization requests and above-average denial rates.

Here's a breakdown of the denial rates for some Medicare Advantage insurers in 2022:

These variations in prior authorization practices and denial rates highlight the importance of understanding the specific policies and procedures of each Medicare Advantage insurer.

Humana plans have the highest number of prior authorization requests per enrollee, with a staggering 2.9 requests per enrollee.

This is significantly higher than other Medicare Advantage insurers, such as Kaiser Permanente, which has a low of 0.5 requests per enrollee.

The high number of prior authorization requests in Humana plans may be due to differences in the services subject to prior authorization requirements, or the frequency with which contracted providers are exempted from those requirements.

For example, Humana's prior authorization process may be more onerous than others, making it more difficult for enrollees to access the care they need.

This highlights the importance of understanding the specific requirements and processes of your Medicare Advantage plan, including the number of prior authorization requests you can expect.