What is Prior Authorization and How Does It Work?

Sometimes you might visit your doctor, and learn that you must seek something called “prior authorization” for a medication or procedure. What is this, and why do you need it? Without prior authorization, your healthcare plan might not pay for the service, so it’s important to pay attention if your doctor or pharmacist mentions this term.

Your insurer might require prior authorization in some circumstances, for the following reasons:

• To ensure that the service or medication is truly medically necessary
• To ensure that the service or medication is the most up-to-date for your situation
• To keep costs low; if two medications both treat your condition, your insurer might want to know why the more expensive one was requested
• To prevent duplicated services when you’re seeing several doctors
• To ensure that an ongoing service is actually helping you

Most of the reasoning for prior authorization revolves around making sure you’re getting the appropriate treatment for your condition. But of course, keeping costs low will help us all. The main purpose behind prior authorization is to ensure that funds are being spent on the right services or medications for the patients who truly need them. That way, we all receive the care we need, when we most need it.

How to get prior authorization. One criticism of prior authorization is that it can create a delay in treatment, so it’s important to follow instructions promptly and correctly. Your healthcare provider’s office should be able to help you, by providing the correct paperwork. Make sure to fill out these forms completely and correctly, to prevent unnecessary denials and appeals. Keep copies of your prior authorizations, including dates, so that you can prove your case if the need should ever arise.

Finally, communicate with your doctor. Ask what happens if the prior authorization is denied; is there a back-up plan for treatment, or is there some other route you can take? Sometimes you might need to appeal a denied prior authorization, but in other cases you will need to proceed with an alternate service or medication.

For more information on prior authorizations, communicate directly with your healthcare plan’s customer service representatives.