Updated March 16, 2015.

If you’re facing a prior-authorization requirement, also known as a pre-authorization requirement, you must get your health plan’s permission before you receive the health care service or drug that requires pre-authorization. If you don’t get permission from your health plan, your health insurance won’t pay for the service. You’ll be stuck paying the bill yourself.

Here are some tips to help get that prior authorization request approved.

Talk to the Person Who Can Make the Decision

While it’s your health insurance company that requires pre-authorization, it’s not necessarily your health insurance company that makes the decision about whether your prior authorization request is approved or denied. Although a few health plans still do prior authorizations in-house, many contract these tasks out to benefit management companies.

Your health plan may contract with a radiologic imaging benefits management company to process its prior authorization requests for things like MRI and CT scans. It may contract with a behavioral health benefits management company to process prior authorization requests for mental and behavioral health benefits. It may contract with a pharmacy benefits management company to process prior authorization requests for certain prescription drugs or specialty drugs.

If you need to speak with a human in an effort to get your prior authorization request approved, the human most likely to help you is the clinical reviewer at the benefits management company, not someone at your health insurance company.

The clinical reviewer is the person who makes the decision to approve your prior authorization request.

If you’re not sure which benefits management company is handling your prior authorization request, your health plan will point you in the right direction. But, don’t count on your health plan personnel to be able to make the decision about approving or denying your request. Save your breath until you speak to the person who actually makes the decision.

Look at the Clinical Guidelines Used to Make Decisions Before You Submit a Prior Authorization Request

In some cases, you can see the clinical guidelines the reviewers base their decisions on. This is kind of like seeing the answers to a quiz before taking the quiz, only it's not cheating.

• See the guidelines National Imaging Associates uses for their decisions about requests for imaging studies here. (This links to a large pdf document that may take a moment to load.)
• Take a look at Tricare’s “Medical Necessity & Prior Authorization Forms/Criteria” site. In the two right columns of the chart, you’ll be able to open up documents describing exactly what criteria meets Tricare’s requirements for a medical necessity exception for each non-formulary drug.

Don’t know whether or not the guidelines you’re interested are online? Ask your health plan or the benefits management company you’re dealing with for pre-authorization. If its guidelines are online, it’s usually happy to share them.

The more you and your physician know about the guidelines used to approve or deny a prior-authorization request, the more likely it is you’ll submit a request that's easy for the reviewer to approve. You're much more likely to get a speedy approval if you give the reviewer exactly the information they need to make sure you meet the guidelines for the service you're requesting.

When you submit your request for prior authorization:

• Include clinical information that shows the reviewer you’ve met the guidelines for the test, service, or drug you’re requesting. Don't assume the reviewer knows anything about your health other than what you're submitting in this request.
• If you haven't met the guidelines, submit information explaining why not. Let's say the guidelines say you're supposed to try and fail drug A before being approved for drug B. You didn't try drug A because you're actively trying to get pregnant and drug A isn't safe for a developing fetus. Spell that out clearly in your prior-authorization request. 

Be Careful About the Information You Submit With Your Prior Authorization Request

When you submit a prior authorization request, make sure the information you submit is totally accurate and is thorough. I can’t tell you how many times I’ve seen prior authorization requests denied or delayed because of stupid mistakes like having the request submitted for a patient named John Appleseed when the health plan member’s health insurance card lists the member’s name as Jonathan Q. Appleseed, Jr.

A computer may be the first “person” processing your request. If the computer is unable to find a health plan member matching the information you submit, you could be sunk before you’ve even started.

Likewise, it may be a computer that compares the ICD-9 or ICD-10 diagnosis codes with the procedure CPT codes you submit, looking for pairs that it can approve automatically using a software algorithm. If those codes are inaccurate, a request that might have been quickly approved by the computer will instead be sent to a long queue for a human reviewer to analyze. You’ll wait another few days before you can get your mental health services, your prescription drug, or your MRI scan.

If you’re having trouble getting prior authorization or have had a prior authorization request denied, ask to see exactly what information was submitted with the request. Sometimes, when the clerical staff at a physician’s office submits a prior authorization request, the physician hasn’t yet finished his or her clinical notes about your visit. If the office staff submits copies of your last couple of office visit notes along with the prior authorization request, the notes submitted may have absolutely nothing to do with the medical problem you’re addressing in the prior authorization request.  With clinical information that doesn’t match your request, you’re unlikely to have your prior authorization request approved.

Read more about “How Silly Mix-Ups Cause a Health Insurance Claim Denial.”

Request Denied? Try Again.

If your request for prior authorization has been denied, you have the right to know why. You can ask your doctor’s office, but you might get more detailed information by asking the medical management company that denied the request in the first place. If you don’t understand the jargon they’re using, say so and ask them to explain, in plain English, why the request wasn’t approved.

Frequently, the reason for the denial is something you can fix. For example, perhaps what you’re requesting can only be approved after you’ve tried and failed a less expensive therapy first. Try it; if it doesn’t work, submit a new request documenting that you tried XYZ therapy and it didn’t help your condition.

While you have the right to appeal a prior authorization request denial, it may be easier just to submit a whole new request for the same exact thing. This is especially true if you’re able to “fix” the problem that caused the denial of your first request.

Prior Authorization Requirement—Why to Beware