When is Prior Authorization Needed and How to Get It?

Healthcare system in the United States is very complex. Before the patient decides to see a specialist, the first question that needs to be answered is if he/she has health insurance. There’s a huge variety of group health insurance plans offered through employers, but the system also includes Medicare, Medicaid, the Veterans Health Administration system, and individual plans offered through the insurance markets set up by the Affordable Care Act. The kind of insurance that your patient has can directly influence how much your patient pays for healthcare and what doctors or specialists he/she is permitted to see. This is why health insurance providers are a lot more complicated than any other type of insurance. Over time it gets more complicated as new laws, regulations, court cases and differing opinions start to add complexity.

To ensure that a client's insurance provider will pay up all the required medication and treatment, doctors and other medical professionals require prior authorization to their clients. Under some medical and prescription drug plans, treatments and medications may need approval from the health insurance provider before you provide care.

Prior authorization is usually required if your client needs a complex treatment or prescription. Coverage will not happen without it. One reason why health insurance providers require this type of document before proceeding with different medical procedures is that a less expensive treatment option may be sufficient rather than simply defaulting to the most expensive option. To make sure that reimbursement will not be denied and that you will receive proper compensation, this document must be secured prior to giving your client the required procedure.
 
How to Get Prior Authorization?

If you’re in-network to your patient’s insurance coverage, then you have to prepare the necessary documents for your patient. Prior-authorization procedures are different from every insurance provider.

Submission of Prior Authorization Request
 
You submit your pre-authorization request by mail or fax. Many authorization companies provide Prior Authorization Request Form (both offline and online) to submit written pre-authorization. Every insurance company has its own requirements for pre-authorization requests. However, you should include the following information in all types of requests.

• Demographic information of the patient (name, date of birth, insurance ID number and more)
• Provider information (both referring and servicing provider)
  • Tax ID number
  • National Provider Identifier (NPI) number
  • Address where services are being provided
  • Phone and fax number
• Requested service/procedure along with specific CPT/HCPCS codes
• Diagnosis (corresponding ICD code and description)
• Location where the service will be performed
  • Tax ID number
  • NPI number
  • Address
  • Phone and fax number
• Length of stay requested in case of inpatient requests

 
How Long Do Prior Authorizations Take?

• A prior authorization can take days to process. However, being proactive and maintaining a very detailed communication log can help to reduce the amount of time a prior authorization takes.
• Also, keeping some sort of alert/calendar so that you know when the first request was sent and following a very strict follow-up schedule will help you avoid the dreaded delay that is typically caused by prior authorizations. Below are a few tips to reduce the time spent processing prior authorizations:

1. Start the process early.
2. Know the key dates for when your information needs to be submitted.
3. Send a follow-up fax or phone call if the requested authorization has not been returned within 5 business days.
4. Don’t hesitate to ask if you need a short-term process.
5. Have your patient be involved in the process to expedite the approval.

The process of obtaining and maintaining prior authorizations is vital to the success of any medical practice. Overall, the prior authorization process impacts almost every aspect of the revenue cycle and operations of your medical practice.
 
HOW TO REQUEST A GAP EXCEPTION/ PRIOR AUTHORIZATION FOR OUT OF NETWORK CARE How to request a gap exception/ prior authorization for out of network ... (n.d.). Retrieved August 6, 2022, from https://favoredmedicalbilling.com/forms/GAP_Request_Guide_for_Midwives_and_Birth_Centers.pdf
 
References

Lower burden with outsource prior authorization: Drcatalyst. English. (n.d.). Retrieved August 6, 2022, from https://www.drcatalyst.com/importance-of-prior-authorization

Prior authorization. Santa Clara Family Health Plan. (n.d.). Retrieved August 6, 2022, from https://www.scfhp.com/for-providers/provider-resources/prior-authorization/

Clements, J. (2022, July 14). What is prior authorization? when is it needed and not? Outsource Strategies International. Retrieved August 6, 2022, from https://www.outsourcestrategies.com/blog/what-is-prior-authorization-when-is-it-needed-and-not/