Prior authorization

Prior authorization is your health plan’s approval, given before you receive a service or drug, that it will pay for it. Imaging, surgery, specialty drugs and rehabilitation stays are the usual candidates, and without the approval the plan can refuse to pay even for care that was appropriate. Emergency care is the exception. It cannot be approved in advance, so an emergency claim denied for lack of approval should go back to the plan for reprocessing.

The request usually comes from your provider. The office that orders the scan or writes the prescription submits it with the clinical notes, and for a prescription it is not something you can file yourself. What you control is timing and follow-up. Prior authorization is also one stage of a wider process, utilization review, in which the plan checks whether covered care is medically necessary. Before the care, it is prior authorization. During an inpatient stay or a continuing course of treatment, it is concurrent review, which can cut the stay or the course short. After the care, it is retrospective review, the source of surprise denials on bills.

Two things catch people. An approval is not a payment: keep the approval letter and its reference number, because a claim can still be denied afterwards, and that number is your evidence. And prescriptions often face a second gate. Step therapy makes you try a cheaper drug first; if you already have, the prescriber can request an exception, which turns on the dates and outcome of what you tried.

You usually meet prior authorization secondhand. The doctor’s office says it is waiting on the plan, or the pharmacist reads out a rejection that says prior authorization required, which is a task for the prescriber rather than a final answer. A written denial should name the reason, the clinical criteria the reviewer applied and the deadline for your next step; if any of the three is missing, or all you got was a phone call, ask for it in writing. Medicare Advantage plans commonly require approval for imaging, procedures and specialist visits; Original Medicare generally does not.

In New York: the state switches prior authorization off in one area and sets the appeal route for the plans it regulates. At an OASAS-certified facility in your plan’s network, the plan may not require preauthorization for outpatient addiction treatment, and may not run concurrent review for the first two weeks of continuous treatment, up to 14 visits, provided the facility notifies the plan within 48 hours. Out of network, at an uncertified facility, or without that notice, the rule does not apply. Plans that cover prescription drugs must give immediate access, without prior authorization, to substance use disorder medications on the state list. On Medicaid, most members’ prescriptions run through NYRx, with one statewide drug list and one set of prior authorization rules. When a plan says no, you file an internal appeal first, with a letter of medical necessity from your clinician, then an external appeal through the Department of Financial Services, decided by a reviewer who does not work for your insurer and binding on the plan. That route covers plans the state regulates; a self-funded employer plan uses federal external review, and the addiction-treatment rule does not reach it. On Medicaid, the plan appeal leads to a fair hearing, and if you already receive the service, ask for aid continuing within about 10 days. Every appeal deadline that binds you is printed on the denial letter, and it differs by plan and stage, so take the date from the letter.

• Ask the ordering office who handles authorizations and when the request will go in, and ask for a copy of what it submits.
• If the plan denies it, ask for the denial in writing with the reason, the criteria used and the appeal deadline, and ask the office to request a peer-to-peer review with the plan’s reviewer. How to appeal.
• For a drug, ask the pharmacy for an emergency or temporary supply while the request is pending. When a plan will not cover a drug.
• If waiting would cause harm, ask for the expedited track by name and have the prescriber state why.

Also called: pre-authorization, precert, prior auth. Full guide: How to appeal a denial in New York. Reference: Prior authorization on Wikipedia — general definition, not New York specifics.