Don't Despair if You've Been Denied Prior Authorization

There are still steps you can take to get your medical care covered, even if your health plan has denied prior authorization.

There are still steps you can take to get your medical care covered, even if your health plan has denied prior authorization.

Prior authorization, sometimes known as prior approval or preauthorization, is approval from your insurance company to obtain treatment, medication, or a medical device. Insurance companies often require prior authorization in order to reduce medical waste and help keep their costs manageable. It’s important to understand your insurer’s policy on prior approval, and never a bad idea to call your insurer before seeking specialty medical care in order to avoid a surprise bill. Oftentimes, your healthcare provider’s office can seek prior authorization from your insurance company on your behalf.

What happens if you are denied prior authorization? First, it’s important to understand why the preauthorization was not granted. Check your explanation of benefits (EOB) guide to determine if the procedure or medication you are seeking is covered by your plan. For instance, many insurance companies will not cover cosmetic surgeries or infertility treatments. Unfortunately, if your treatment is not covered in the EOB guide, it will be challenging to obtain prior authorization. On the other hand, if the medication or procedure is included in your EOB guide, it is possible that preauthorization forms were incomplete or improperly submitted by your healthcare provider’s office. For this reason, gathering information on why you were denied prior approval is critical.

If you’ve determined that the treatment or medication is included in your insurance benefits, you are entitled to appeal the decision by your insurance company. In this case, it’s a good idea to employ the help of doctors and hospitals as advocates on your behalf. If your physician is able to provide more information on the necessity of a medication, device, or treatment, the insurance company may be more likely to revisit your claim. Additionally, your doctor’s office may be able to fix any errors that were made in the process of filling out prior authorization forms.

If, after speaking with your insurance provider and appealing your prior authorization request, you are still unable to get preapproval for a medication or treatment, talk with your doctor about medical alternatives. Is there a generic drug that could be substituted for the brand-name version? If your prior authorization was denied because you were attempting to see an out-of-network provider, is there someone in-network that can treat you? As a last option, if it is financially possible for you to pay out-of-pocket for your treatment or medication, you may bypass using your insurance for your treatment or medication. For many, this is not financially feasible, so be sure to explore all of your options, including speaking with your insurance company and doctor, before financing your own medical expenses.

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