Q: What is prior authorization?
Prior authorization, also known as precertification or prior approval, is a process used by insurance companies to determine whether or not a prescribed product or service will be covered. Healthcare providers must receive approval from the patient's insurance company before delivering products or services to ensure they are covered, which can sometimes lead to delays in receiving treatment.
Q: Why do some medications require prior authorization from my insurance?
Insurance companies use prior authorization to ensure that a medication is medically necessary and meets their coverage criteria. This process helps manage costs and ensures that patients receive the most appropriate and cost-effective treatment options.
Q: What is a letter of medical necessity, and when is it needed?
A letter of medical necessity is a document written by your doctor explaining why you need a specific medication, including details about your medical condition and why alternative treatments may not be suitable. It is often required when seeking approval for prior authorization or an exception to your insurance plan’s formulary.
Q: When can I expect to know whether or not authorization was granted?
The time it takes to receive authorization ranges from a few days to a few weeks, depending on the urgency and complexity of the case. Standard medication requests usually require a few days with a possibility of expediting the process depending on the circumstances. Special medications and treatments usually require a few weeks.
Q: What do I do if the insurance company denies authorization?
Submit an appeal through your provider's office. An appeal is a formal request for your insurance company to reconsider its decision and review your case again. It usually includes any new or additional information given by your healthcare provider and an explanation as to why the prescribed treatment is necessary and the best course of action. You have up to 6 months (180 days) after receiving a denial to file an appeal.