How to Get a Prior Authorization Request Approved

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 healthcare service or drug that requires it.

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.

Assuming you’re using a medical provider who participates in your health plan’s network, the medical provider’s office will make the prior authorization request and work with your insurer to get approval, including handling a possible need to appeal a denial.

But it’s in your best interest to understand how this process works and advocate for your own care if necessary, since your health plan won’t cover the treatment until the prior authorization is approved.

This article will give you some tips to help get that prior authorization request approved.

Talk to the Decision-Making Person

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 magnetic resonance imaging (MRI) and computed tomography (CT) scans.

They may contract with a behavioral health benefits management company to process prior authorization requests for mental and behavioral health benefits. Your plan 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 someone in an effort to get your prior authorization request approved, the person most likely to help you is the clinical reviewer at the benefits management company. That person makes the decision to approve your prior authorization request, not someone at your health insurance company.

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.

Read the Clinical Guidelines First

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.

Don’t know whether or not the guidelines you’re interested in 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 healthcare provider 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 your healthcare provider submits a request for prior authorization or appeals a rejected prior authorization, they should:

  • 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 and your doctor are submitting.
  • 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. Make sure that’s clearly explained in your prior authorization request. 

Submit Thorough and Accurate Info

When you submit a prior authorization request, make sure the information you submit is totally accurate and is thorough. Prior authorization requests can be denied or delayed because of seemingly mundane mistakes.

A simple mistake could be 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-11 diagnosis codes with the procedure CPT codes your healthcare provider submits in the prior authorization request, 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 healthcare provider’s office submits a prior authorization request, the healthcare provider 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 not have all of the pertinent details about 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.

Request Denied? Try Again

If your request for prior authorization has been denied, you have the right to know why. You can ask your healthcare provider’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.

Or if there’s a reason you can’t do that (perhaps the treatment you’re supposed to try first is contraindicated for you due to some other condition or circumstance), you and your healthcare provider can provide documentation explaining why you cannot safely comply with the insurer’s protocol.

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.

If you and your doctor feel that an appeal is the best course of action, know that the Affordable Care Act ensures your right to an internal and external appeals process (assuming you don’t have a grandfathered health plan, which are policies that were already in effect when the ACA was signed into law in 2010).

Make Sure Your Insurer Follows the Rules

It’s also important to make sure that your insurer is complying with the applicable federal and state regulations regarding prior authorization.

For example, an insurer cannot require prior authorization to determine medical necessity for mental health or substance abuse treatments if they don’t have a similar protocol for medical/surgical treatments.

Most plans cannot require prior authorization before a member sees an OB-GYN or before emergency services are received. And many states impose their own requirements for state-regulated (ie, non-self-insured) health plans in terms of the length of time they have to complete prior authorization reviews and respond to appeals.

Your healthcare provider’s office is likely well-versed in the applicable rules, but the more you understand how they work, the better you can advocate for your own healthcare needs.

Summary

Prior authorization is a process that health plans use to ensure that certain medical procedures (especially those that are expensive) are only used when medically necessary and when a less-expensive treatment option would not suffice.

Each insurer sets its own guidelines in terms of which services require prior authorization. As long as the patient is using an in-network medical provider, the provider will typically submit the necessary documents and obtain the prior authorization on the patient’s behalf. But it’s useful for the patient to understand what’s going on, and to be able to advocate for the care they need, especially if the prior authorization request is initially denied.

A Word From Verywell

As long as you’re seeking care that’s medically necessary and covered by your health plan, your prior authorization request should be approved. But that’s not always the case. It’s important to wait until the request is approved before receiving the service, as you could otherwise end up having to pay the whole bill yourself. But don’t give up if a prior authorization request is initially denied—there are lots of reasons for this, and it’s often possible to get that decision reversed by appealing or providing additional information to your health plan.

Frequently Asked Questions


  • What is pre-authorization for insurance?

    Pre-authorization, also known as prior authorization, is a process insurance companies make patients go through to have medical treatments covered. Your insurance company determines the medical necessity of health care services, treatment plans, medications, or equipment in advance of your receiving care.

    If your insurance requires pre-authorization, you must get it approved before the treatment. If you do not get prior authorization first, your insurance company may deny payment after the fact. 


  • What is the difference between preauthorization and precertification?

    Preauthorization and precertification are terms that are often used interchangeably in health care. However, there is a slight difference between the two. Preauthorization typically requires medical records and other documentation to prove why a treatment was chosen to determine if it is medically necessary. Precertification typically does not require backup documentation. 


  • Who is responsible for acquiring preauthorization?

    If your healthcare provider is in-network, they will typically handle all of the paperwork for obtaining precertification or preauthorization. If the provider is out-of-network, they may or may not handle the paperwork for you. It may be up to you to send the forms to the insurance company.


  • What happens if prior authorization is denied?

    If your insurance company denies pre-authorization, you can appeal the decision or submit new documentation. By law, the insurance company must tell you why you were denied. Then you can take the necessary steps to get it approved.

    For example, your insurance company protocol may state that in order for a certain treatment to be approved, you must first try other methods. If you have already tried those methods, you can resubmit documentation and it will likely be approved.