OBTAINING PRIOR AUTHORIZATION

Real Life


"My insurance authorized pulmonary endarterectomy surgery for $75,000. After going through the preliminary tests, it was determined that I wasn't a candidate for the surgery. The tests amounted to $13,000. My insurance wasn't paying the hospital, so the hospital notified me.

Fortunately I had a copy of every authorization for every test and procedure. I worked for weeks with the hospital billing department and with my insurance, and ultimately they had to pay what they had authorized. The point is, be persistent and make the insurance company honor their authorization letters."

Prior authorization can seem like an unnecessary and aggravating reality when it comes to accessing your treatment. However, there are some steps you can take to streamline the process.

If you suspect or know that you will need to get your medical services or treatment approved before you can receive them, take action now:

  • Call your insurance company.
    Because each insurance company has a unique prior authorization process and step therapy process, the only way to know if your insurance company requires approval for a particular treatment beforehand is to call and ask.


    When calling to inquire about prior authorization, be sure to ask the following questions:

    • Does my plan require prior authorization for coverage of this particular service or product? For example, does my plan require prior authorization for an infusion pump? Do I have to get prior approval for my bosentan prescription?

    • How do I get something prior authorized? What is the process? Who must make the prior authorization request – physician, patient, nurse?

    • What is the address, fax number or phone number to call to send the request to?

    • What documentation should be included? Be sure to ask what paperwork or proof they will need.

    • How long will it take for a decision to be made? If they say they are "not sure," ask, "How long does it usually take?"

    • If prior authorization is given, how long is it approved for or when will the approval time “expire?”

    • How will I find out if it has been approved or not?

  • Make your medical providers aware and seek their assistance. The decision to cover a treatment is based on information that your doctor or nurse gives them.

    For some programs, your doctor may have to call or send a special letter called a "Statement of Medical Necessity" or "Letter of Medical Necessity” that justifies the service rendered as reasonable and appropriate for the diagnosis or treatment of a medical condition or illness.

    It is often helpful to include a letter of medical necessity from your physician, even if your company does not require it. View a sample letter of medical necessity

  • Follow up in writing after speaking with a health plan representative on the phone. Keep your correspondence simple and to the point. Include relevant dates, names of representatives with whom you spoke and their message to you. Also be sure to include your name, policy number and any other identifying information.

  • Carefully follow the steps outlined by your health plan. Otherwise, your request could be delayed or even denied.

 

 

Contact us with insurance questions, success stories, suggestions, or requests to volunteer.


PHA is proud to be able to make educational materials and programs like these available for free to everyone because of the generous support from members of the community just like you. Donations are welcome!

The information provided on the PHA website is provided for general information only. It is not intended as legal, medical or other professional advice, and should not be relied upon as a substitute for consultations with qualified professionals who are familiar with your individual needs.

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The National Organization for Rare Disorders (NORD) awarded PHA the Abbey S. Meyers Leadership Award in 2012 for outstanding service to PHA members in advocacy, education and other key areas.