What Is Prior Authorization? Your Guide to Approvals

Prior authorization is a requirement from your health insurance plan to approve certain medications, tests, or procedures before you receive them. It confirms the treatment is medically necessary and covered by your plan before you incur any costs, and is a check-in process used by health insurance companies. It is also sometimes called pre-authorization, pre-certification, or simply PA.

Think of it like getting permission before making a large purchase on a company credit card. Before the health plan agrees to cover a specific medicine, service, or medical device, they need to review it. They want to make sure the treatment is safe, necessary for your condition, and covered by your specific health plan.

This process happens before you receive the care or pick up the medication. If you get the service without this approval, your health plan might not pay for it. This could leave you responsible for the whole bill.

Prior Authorization Is Not a Referral

It is important to know the difference between prior authorization and a referral.

• Referral: This is when your primary care provider (PCP) recommends you see a specialist, like a dermatologist or cardiologist.
• Prior Authorization: This is when your health plan reviews a specific treatment or drug to decide if they will cover the cost.

Why Do Insurers Require Prior Authorization?

You might wonder why your doctor’s prescription is not enough. Why does the health plan need to weigh in? There are a few key reasons:

1. Safety: Some drugs have serious side effects or can interact with other medicines. The review process checks to make sure the treatment is safe for you.
2. Cost: Healthcare can be expensive. Health plans want to make sure you are getting a treatment that works well but doesn’t cost more than needed. If a generic drug works as well as a brand-name drug but costs less, the plan will prefer the generic.
3. Medical Necessity: The plan needs to confirm the treatment is medically necessary for your specific condition. For example, a medicine may be approved for diabetes but not for weight loss.
4. Avoiding Repeat Services: If you just had an X-ray last week, the plan may question why you need another one. This helps prevent waste and extra exposure to radiation.

Common Situations: When Do You Need Prior Authorization?

Not every visit to the doctor requires a prior authorization. Routine checkups, standard blood work, and common generic antibiotics usually do not need extra paperwork. More complex or high-cost treatments often require a review.

Here are the most common areas where you will encounter this requirement.

1. Prescription Medications

   This is the most common time members need prior authorization. It often happens with:

   • Brand-name drugs: If there is a generic version available, the plan usually wants you to try that first.
   • Specialty drugs: These are medications used for complex conditions like rheumatoid arthritis, multiple sclerosis, or cancer. They are often very expensive and require special handling.
   • Drugs with potential for misuse: Painkillers, especially opioids, often require approval to prevent misuse and ensure safety.
   • Cosmetic vs. Medical Use: Some drugs can be used for appearance or for health. The plan checks to make sure it is for a medical reason.
2. Advanced Imaging and Tests

   While a standard X-ray is usually simple, advanced imaging often needs approval. This includes:

   • MRI scans (Magnetic Resonance Imaging)
   • CT scans (Computed Tomography)
   • PET scans (Positron Emission Tomography)

   These tests can be expensive and may not be needed for every situation. The health plan may ask if a less expensive test, like an ultrasound or basic X-ray, can be done first.

3. Medical Procedures and Surgeries

   Planned surgeries almost always require prior authorization. This includes procedures like:

   • Knee or hip replacements
   • Back surgeries
   • Organ transplants
   • Non-emergency heart procedures

   Emergency surgery is handled differently. If you need life-saving surgery after an accident, doctors act right away. The authorization process happens later, once you are stable. Never delay emergency care to wait for paperwork.

4. Durable Medical Equipment (DME)

   This equipment is used at home to help manage a health condition. Examples include:

   • Insulin pumps
   • Hospital beds for home use
   • Wheelchairs, especially electric models
   • Oxygen tanks
   • Sleep apnea machines (CPAP)
5. Home Health and Therapy Services

   If you need ongoing care, the plan may approve a set number of visits. This may include:

   • Physical therapy
   • Occupational therapy
   • Speech therapy
   • Skilled nursing care at home

   For example, your plan may approve 10 physical therapy sessions. If you need more, your therapist will need to request approval again.

The Step-by-Step Prior Authorization Approval Process

Knowing who does what can help lower your stress. Here is how the process usually works, from when your doctor suggests a treatment to the final decision.

Step 1: The Prescription or Order

Prior Authorization starts when your healthcare provider decides you need a specific medicine or service. They write a prescription or order.

• At the Pharmacy: You might drop off a prescription, and the pharmacist tells you, “Insurance says this needs prior authorization.” The pharmacist cannot fix this; they must contact your doctor.
• At the Doctor’s Office: Your doctor may tell you, “We need to get this approved by your insurance first.”

Step 2: The Request Submission for Prior Authorization

Your doctor is responsible for this step. You usually cannot send the request yourself because it needs detailed medical records.

Your doctor’s office sends a form to your health plan. This form includes:

• Your diagnosis (why you need care)
• The treatment they want to use
• Medical notes showing why you need this specific treatment
• History of other treatments you have tried that did not work (this is called “step therapy”)

Step 3: The Review for Prior Authorization

Once the health plan gets the prior authorization request, a team will review it. The team usually includes nurses, doctors, or pharmacists. They check your plan’s rules and medical information.

They may ask questions like:

• Is this drug covered on the plan’s drug list (also called the formulary)?
• Is the dose right?
• Have you tried less expensive or safer options first?
• Is the treatment considered experimental?

Step 4: The Decision

The plan will send a decision on whether they approve to your doctor and to you.

• Approved: You can pick up your medicine or schedule your procedure. The letter will tell you how long the approval lasts.
• Denied: The plan will not cover the cost. The letter must explain why.
• More Information Needed: Sometimes, the doctor did not send enough notes. The plan will ask for missing information before making a decision.

How Long Does Prior Authorization Take?

Waiting for medical care is tough. You want to feel better as soon as possible. The timeframe for prior authorization can vary, but here is what to expect.

Standard Requests

For non-urgent situations, the process usually takes 3 to 5 business days. In some cases, it may take up to 14 days, depending on state rules and the complexity of your case.

Urgent Requests

If your life or health is at serious risk, your doctor can mark the request as “urgent” or “expedited.” In these cases, health plans usually decide within 24 to 72 hours.

It is important that your doctor explains why your authorization is urgent. Needing the medicine sooner is usually not enough; there must be a clear medical risk from waiting.

Prior Authorization Delays

Common reasons for delays include:

• Incomplete information: The doctor forgot to attach lab results or notes.
• Incorrect forms: The office used an old form or the wrong code.
• Administrative errors: The fax did not go through or a name was misspelled.

"Step Therapy" and "Quantity Limits" in Prior Authorization

When talking about prior authorization, you might hear about “step therapy” and “quantity limits.” These are rules plans use to manage safety and costs.

What Is Step Therapy in Prior Authorization?

Step therapy, also called “fail first,” means you must try a standard or less costly drug before trying a newer or more expensive one.

Example:

You have high blood pressure. Your doctor prescribes a new brand-name drug. The health plan denies it and suggests a well-tested generic instead.

• Step 1: Try the generic drug. If it works, you save money and get healthy.
• Step 2: If the generic does not work or causes problems, your doctor documents this. The plan may then approve the original, more expensive drug.

This rule helps make sure members use the most cost-effective care that still works well.

What Are Quantity Limits in Prior Authorization?

This rule controls how much medication you can get at one time or over a set period.

• Safety: Stops risks like overdose or addiction, especially with strong pain medicine.
• Preventing waste: Stops you from getting a big supply of a drug you may only need for a week.

If your doctor thinks you need more than the limit, they can ask for prior authorization to explain why you need a larger supply.

What You Can Do to Speed Things Up for a Prior Authorization

Your doctor handles the paperwork, but you can still help. You do not have to sit and wait. Here are some simple steps you can take to keep things moving.

1. Ask Questions at the Appointment

   When your doctor prescribes a new drug or test, ask right away:

   • “Do you think this will require prior authorization?”
   • “Is there a generic alternative we can try first?”
   • “Will your office start the paperwork today?”
2. Check your Health Plan Formulary

   Every health plan has a drug list called a formulary. This shows which medicines are covered. You can usually find this on your plan’s website or by calling Member Services.

   • Look up the drug your doctor prescribed.
   • See if it has a “PA” (prior authorization) or “ST” (step therapy) note next to it.
   • If it does, tell your doctor so they know to submit the right paperwork.
3. Follow Up

   If you have not heard back in three days, call your doctor’s office. Ask for the person who handles authorizations and check:

   • “Was the request submitted?”
   • “Did you get a confirmation number?”

   If the doctor’s office says they sent it, you can then call your health plan. Having the confirmation number helps the health plan representative find your case.

4. Be the Bridge

   Sometimes the doctor’s office is waiting on the health plan, and the health plan is waiting on the doctor. You can help break this cycle.

   • Ask the health plan what is missing (for example, “We need the January lab results”).
   • Call the doctor and say, “The health plan is waiting for the January lab results. Can you send those today?”

What If Your Request Is Denied for Prior Authorization?

Hearing “no” can be stressful, but a denial is not always the final answer. It is common for decisions to be changed to “yes” after further review.

Read the Denial Letter

You will get a letter explaining the denial. Do not throw it away. It helps you fix the issue. Look for the specific reason:

• “Not medically necessary:” The doctor might need to send more notes proving you need it.
• “Step therapy required:” You may need to try another drug first or prove you already did.
• “Administrative error:” A date or code could be wrong.
• “Benefit exclusion:” Your plan does not cover this type of service, such as cosmetic surgery.

Contact Your Prescriber

Show the letter to your doctor. The doctor may request a peer-to-peer review, which is a phone call with a doctor from the health plan. They discuss your case in detail and may solve the problem right away.

Filing an Appeal for Prior Authorization Approval

If a peer review does not work, you can file an appeal. An appeal is a formal request to have the health plan take another look at your case to grant prior authorization approval.

How to Appeal:

1. Call Member Services: Tell them you want to appeal a denial. They will explain the steps and may send you a form.
2. Write a Letter: You or your doctor can write a letter explaining why the denial should change. Include new evidence, such as notes from specialists.
3. Keep Records: Save copies of everything you send and take notes when talking to anyone about your case.
4. Timelines: Watch the deadlines. You usually have a certain number of days (like 60 or 180) to file an appeal after a denial.

External Review Request for Prior Authorization

If your appeal is denied, you can request an “external review.” An independent third party looks at your case. Their decision is usually final and binding.

Avoiding Surprise Costs with Prior Authorizations

One of the biggest risks with prior authorization is a surprise bill. This happens when you get care thinking it is covered, but then discover it was not approved.

Tips to Protect Your Wallet:

• Never assume: Do not assume your doctor checked with your health plan. Always ask for confirmation.
• Get it in writing: If you talk to someone at your health plan by phone, ask for a reference number or a copy of the approval letter.
• Do not pay the full price yet: If the pharmacy says your medicine costs much more than usual, ask if it is a prior authorization issue. Waiting may help you avoid paying out of pocket.
• Stay in network: Even with prior authorization, you save money by using in-network doctors and hospitals. Out-of-network care can cost more, even if it is approved.

How Ambetter Health Supports You

At Ambetter Health, we know health insurance can be confusing. You should not have to be an expert to get the care you need. Our goal is to make quality healthcare accessible and easy to understand.

If you are an Ambetter Health member and you are confused about prior authorization, we are here to help.

• Call Member Services: Our team can check your specific plan details. We can tell you if a drug needs approval, check the status of your request, or explain any letter or form you receive.
• Use your Online Member Account: You can log in to your online member account to view claims and coverage documents. This is a fast way to check your formulary (drug list) or see if a procedure is covered.
• Get Care Coordination: For members with complex health needs, we offer programs to help coordinate care. We work with your doctors and providers to keep everyone on the same page.

Ambetter Health is your trusted ally. We empower you with clear information so you can focus on your health.

Your Action Plan

Here is a simple checklist to use the next time you need a new medication or procedure.

1. Ask at the appointment: “Does this require prior authorization?”
2. Check your plan: Review your formulary or benefit guide online.
3. Wait for approval: Do not schedule surgery or pay for an expensive drug until you know it is approved.
4. Follow up: If you do not hear back in 3 to 5 days, call your doctor and your health plan.
5. Appeal if needed: If denied, read the letter and ask your doctor to help you appeal.

Prior authorization helps ensure care is safe, effective, and affordable. Understanding how it works puts you in control of your care. You are your own best advocate, and support is always available.