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Deb Gordon

Deborah D. Gordon has spent her career trying to level the playing field for health care consumers. She is author of "The Health Care Consumer's Manifesto: How to Get the Most for Your Money" (Praeger 2020), based on consumer research she conducted as a senior fellow in the Harvard Kennedy School's Mossavar-Rahmani Center for Business and Government. Deb previously spent more than two decades in health care leadership roles, including Chief Marketing Officer for a Massachusetts health plan and CEO of a health technology company. Deb is an Aspen Institute Health Innovators Fellow, an Eisenhower Fellow, and a Boston Business Journal 40-under-40 honoree. Her contributions have appeared in JAMA Network Open, the Harvard Business Review blog, USA Today, RealClear Politics, The Hill, and Managed Care Magazine. She earned a BA in bioethics from Brown University, and an MBA with distinction from Harvard Business School.

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What You Need to Know About Prior Authorization

What You Need to Know About Prior Authorization

Without prior authorization, health insurers can deny coverage and not pay for services or treatments, but consumers can appeal

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Prior authorization is permission — or preapproval — from a health insurance company for a healthcare service, treatment, medication or procedure. 

Did you know? Without prior authorization, health insurers can deny coverage and not pay for services or treatments that require preapproval. 

Healthcare providers (HCPs) often submit prior authorization requests for patients, but you may end up being responsible for making sure their services are approved. This may mean you have to file an appeal if your request is denied.

Fact: The Affordable Care Act, or ACA, gives you the right to appeal a health plan decision.

Appealing a Prior Authorization Denial 

There are two types of insurance appeals:

Internal: You have the right to ask your health insurer to reconsider a denial, and they are required to review their decision — and may reverse it.

External: You have the right to ask for an independent third party to review the denial. There are companies whose role it is to review and either keep or reverse the original decision. The insurance company is legally required to follow the company’s decision. 

Fact: If your situation is urgent and waiting weeks for an appeal would put your health at risk, you can ask for a faster decision. Expedited appeals can happen within days. 

How to File an Appeal if Your Request Is Denied

Your insurance company must notify you in writing if they deny your prior authorization request and tell you why. Follow these steps to officially ask your insurance company to reconsider:

  1. Gather information. You may need information to show that the treatment or service you requested is medically necessary. Your HCP may be able to help you prepare the appeal.

  1. File an internal appeal with your insurance company. Complete your insurance company’s appeal forms or write a letter that includes the relevant information, such as your name, insurance ID number, claim number and explanation of your case. You may need to include a letter from your HCP or they may file the appeal on your behalf.

  1. If your internal appeal is denied, file an external appeal. External appeals follow state or federal processes, depending on where you live. If your insurance company does not tell you how to request an external appeal, check with your state’s Consumer Assistance Program or insurance regulator.

Tip: Insurers are required to meet certain time frames to decide on prior authorization requests or to review and decide on appeals. 

30 days for a new service

60 days for a service you’ve had before 

Fact: Before giving prior authorization for certain medications, insurance companies often require step therapy, which means you must try the cheapest medication first. 

Get Help With Your Appeal

The prior authorization process can be confusing and frustrating — but there are people who can help you manage it: 

  1. Healthcare providers: Your HCP and their staff likely have experience dealing with insurance plans and know how to navigate the process.

  1. Authorized representatives: Any friend, relative or professional can be appointed as your authorized representative to speak with your insurance company for you.

  1. Patient advocates: Local and national organizations like the Patient Advocate Foundation exist to help people get the care they need. 

  1. State consumer protection agencies: Every state has a department of insurance, and many have consumer protection groups to help patients handle insurance company disputes. 

This resource was created with support from AbbVie.

 

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