Prior Authorization Denied? What to Do Next

Prior authorization, sometimes called preauthorization, is advance approval your health plan may require before you get certain care. Your doctor's office usually sends the request. The plan then decides whether it will cover the service.

A denial at this stage is a decision about a request, not a bill. No claim has been paid or refused yet, and you usually have time to respond. Reasons often include missing or incomplete information, a decision that the care is not medically necessary under the plan's rules, a service the plan does not cover, or a request that did not follow the plan's filing steps.

Your insurer must notify you in writing and explain why it denied the request. For job-based plans, Department of Labor rules say the notice must name the specific reasons and the plan provision relied on. If information is missing, it should describe what is needed and why. It should also explain how to appeal.

If the denial is about medical necessity, the notice must give the clinical reasoning or say it is available free on request. It must also give the rules, guidelines, or protocols the plan used, or say a free copy is available. Ask for them.

For job-based plans, you can also ask for copies of the documents, records, and other information relevant to your claim, free of charge. Those papers show what the plan looked at, so your doctor can answer it directly.

Some prior authorization denials come from missing or incomplete information that the office can fix. When the denial is for a medical reason, the National Association of Insurance Commissioners suggests asking your provider to contact your plan and request reconsideration based on additional information the provider can supply.

Some insurers also allow a call between your doctor and the insurer's reviewing doctor, often called a peer-to-peer review. Ask the insurer whether yours does, and by when your doctor must ask. Whether this is offered, and how long the window lasts, depends on the plan.

Under federal rules for job-based plans, a request is urgent when the normal time frames could seriously jeopardize your life, health, or ability to regain maximum function, or could leave you in severe pain that cannot be managed without the care. If a doctor who knows your condition says the request is urgent, the plan must treat it as urgent.

For an urgent request, the plan must decide as soon as possible and no more than 72 hours after it receives the request. If it needs more information, it must tell you within 24 hours and give you at least 48 hours to respond. If you cannot safely wait, ask your doctor to mark the request urgent.

If the plan receives a request that does not follow its filing steps, it must tell you how to fix it. For job-based plans, that notice is due within 5 days, or within 24 hours if the request is urgent.

If the fix does not work, file an internal appeal. This asks your insurer to take a full and fair second look. You, your doctor, or another representative you authorize can file it. For job-based plans, when a denial rests on medical judgment, the reviewer must consult a health care professional who was not involved in the first decision.

Send your doctor's letter and records with the appeal. You can ask for an expedited internal appeal if the standard timeline would seriously jeopardize your life or your ability to regain maximum function. A decision on an urgent appeal must come as quickly as your condition requires, and job-based plan rules say no more than 72 hours.

If the insurer keeps its denial, many plans let you ask for an independent external review. It covers denials involving medical judgment, including treatment the insurer calls experimental or investigational. In urgent situations you can ask for an expedited external review at the same time as your internal appeal.

Our step-by-step guide to appealing a denied claim walks through the paperwork in more detail.

If your plan was bought in Florida, the Florida Department of Financial Services, Division of Consumer Services, can help with insurance problems. Call 1-877-MY-FL-CFO (1-877-693-5236), 8 a.m. to 5 p.m. ET, Monday through Friday.

Self-funded employer plans are regulated federally under ERISA, not by Florida. If you are in a private-sector employer plan, the U.S. Department of Labor's Employee Benefits Security Administration can answer questions at 1-866-444-3272.

If you are not sure which deadline applies, or you are stuck between your doctor's office and your insurer, talk it through with someone who knows how the process works. Prime Health Consultants advisors are licensed, can explain the claims and appeals process in English and Spanish, and can guide you through the steps when you need it.

An advisor gives guidance only. Your insurer, or an independent external reviewer, is the one that can change the decision.