How Does The Prior Authorization Process Work?

How do I check prior authorization status?

You can check the status of your authorization by calling the Customer Service contact number on the back of your member ID card..

What happens if a prior authorization is denied?

If you believe that your prior authorization was incorrectly denied, submit an appeal. Appeals are the most successful when your doctor deems your treatment is medically necessary or there was a clerical error leading to your coverage denial. One of the best ways to build your appeal case is to get your doctor’s input.

What information is needed for prior authorization?

Here is a sample prior authorization request form. Identifying information for the member/patient such as: Name, gender, date of birth, address, health insurance ID number and other contact information.

How do I appeal a prior authorization denial?

First-Level Appeal—This is the first step in the process. You or your doctor contact your insurance company and request that they reconsider the denial. Your doctor may also request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer insurance review” in order to challenge the decision.

How long does it take for a prior authorization to be approved?

Typically within 5-10 business days of hearing from your doctor, your health insurance company will either approve or deny the prior authorization request. If it’s rejected, you or your doctor can ask for a review of the decision.

Why do prior authorizations get denied?

Insurance companies can deny a request for prior authorization for reasons such as: The doctor or pharmacist didn’t complete the steps necessary. Filling the wrong paperwork or missing information such as service code or date of birth. The physician’s office neglected to contact the insurance company due to lack of …

Why do insurance companies require prior authorization?

Your health insurance company uses a prior authorization requirement as a way of keeping health care costs in check. It wants to make sure that: The service or drug you’re requesting is truly medically necessary. The service or drug follows up-to-date recommendations for the medical problem you’re dealing with.

What should you do with the authorization number once you have prior approval?

What should you do with the authorization number once you have prior approval? Document it in the financial record and on all forms associated with the procedure.

What medications need a prior authorization?

Most common prescription drugs requiring preauthorization:Adapalene (over age 25)Androgel.Aripiprazole.Copaxone.Crestor.Dextroamphetamine-amphetamine (quantity limit)Dextroamphetamine-amphetamine ER (over age 18)Elidel.More items…

Who is responsible for prior authorization?

Health care providers usually initiate the prior authorization request from your insurance company for you. However, it is your responsibility to make sure that you have prior authorization before receiving certain health care procedures, services and prescriptions.

How can I speed up my prior authorization?

16 Tips That Speed Up The Prior Authorization ProcessCreate a master list of procedures that require authorizations.Document denial reasons.Sign up for payor newsletters.Stay informed of changing industry standards.Designate prior authorization responsibilities to the same staff member(s).More items…

What services typically require prior authorizations?

The other services that typically require pre-authorization are as follows:MRI/MRAs.CT/CTA scans.PET scans.Durable Medical Equipment (DME)Medications and so on.