Your Ultimate Cheat Sheet To Prior Authorization

In an attempt to demystify and streamline the prior authorization process, we’re outlining key terms & phrases, plus contact information for major insurance plans. 

Prior authorization, also known as precertification or prior approval, is a utilization management practice where healthcare providers obtain approval from a health plan prior to the delivery of medical equipment, services, or prescription drugs to a patient. This ensures patients qualify for payment coverage under their health insurance. Failure to submit a prior authorization request (PA request) can lead to medical service claim denials or delays in filling prescriptions.

Prior authorization processes affect the workflow of the healthcare system. Healthcare providers report current methods to be time-consuming, with staff spending almost two business days a week completing prior authorizations. Also, wait times in receiving pre-authorizations from health insurance providers create delays in patients accessing medical services and are a leading factor in prescription drug requests being rejected at pharmacies.

Needless to say, it’s a complex process that impacts patients and the healthcare system. In an attempt to demystify and streamline the process, we’re outlining key terms and phrases to know, along with contact information for major insurance plans.

Key terms & phrases 

Preauthorization vs prior authorization

Prior authorization is also referred to as preauthorization. These terms are used interchangeably and both refer to a medical necessity review made by health insurance providers for patients to receive the approval before care is provided (with the exception of a medical emergency). This allows health insurance providers to determine if a medical process or care is necessary or, in some situations, covered. If a treatment is not deemed necessary, there will be no reimbursement. The standards for this review are developed by insurance companies through medical guidelines, utilization, cost, etc. 

Types of treatments and medications with prior authorization requirements:

• Costly medications and treatments
• Likely unsafe drug interactions or combinations
• Processes with relatively cheap alternatives
• Medical treatments and drugs for special health issues
• Misused or abused medical processes and drugs
• Procedures like surgeries, transplants, and imaging
• Mental health, psychological testing, and psychiatric care
• Certain outpatient procedures

If an insurance company determines there’s a need for the PA request, the healthcare provider will have to find out additional details about each CPT code (aka diagnosis code). Additionally, when submitting the final claim, it must get the payer's unique number that matches to the earlier auth request and include it.

Prior authorization forms may differ from plan to plan, but usually health professionals need to provide provider information (name, NPI number, whether they are in network or out of network).

READ MORE: Prior Authorization: What Is It & How Long It Takes

Prior authorization vs referral 

Referral is a written order by a primary care physician that asks a patient to see a specialist or receive medical services. Many healthcare organizations require that patients get a referral before they receive medical care from anyone that’s not their primary care provider (PCP). If a patient goes to see a specialist without the approval of their primary care provider, the patient would have to bear almost all the cost of the treatment. A patient would also have to bear the cost of the treatment if they see a specialist that’s not credentialed by the insurance company.

Prior authorization, on the other hand, is used to determine if a treatment, service, prescription drug, or medical equipment is medically necessary. Insurance companies use prior authorization to see if a patient is eligible to receive certain procedures.  

Predetermination vs prior authorization 

Prior authorization is usually the first step to ensuring that patients have the medical insurance to provide payment for whatever medical procedure or medication they need. It simply functions as a means of confirming a patient's eligibility for specific treatment without stating how much coverage. 

Predetermination, on the other hand, relays coverage specifics and usually includes information like the percentage of coverage available to the patient, how the insurers will pay the claim, and when the medical provider or patient will receive the repayment.

Step therapy 

Step therapy refers to the process by which insurance companies ensure that more affordable or appropriate medications don’t work for a patient before paying for certain medications. This means patients will have to try a different medication before they can receive coverage for the one prescribed by their healthcare provider.

This process is used by insurance companies to regulate costs and prevent avoidable medication use. So if an insurance company determines that there’s a less expensive option which is still effective for the condition than the one prescribed by the healthcare provider, they’ll request you try it first. 

As the name suggests, step therapy often means that medications are divided into many steps. Step one medications (which are usually, but not always, generic) are often covered without any problems.

Insurance providers require evidence that a patient cannot take a step one drug before covering the cost of medication in the following level up. It could also be evidence that the patient attempted it and it was unsuccessful. The number of steps varies; however, two or three are typical for most insurance companies. 

Gold carding

Gold carding refers to the practice where health insurance providers waive prior authorization on services and prescription drugs which are ordered by those with a proven track record of prior authorization approvals.

Peer-to-peer review

A peer-to-peer review is an appeal process that occurs when an insurance company denies a patient’s request for services. Denials may be for medications, medical services, medical orders, and inpatient status.

It involves a scheduled phone conversation between the physician and the insurance carrier’s medical director. During this conversation, the physician discusses the importance of the procedure or drug with the medical director. This process functions as an appeal to a denied prior auth request but can also help in obtaining prior authorization.

Nudges

Nudges are used to guide patients towards making efficient decisions during the prior authorization process. The goal: streamline the process, reduce administrative burdens, and ensure that medically necessary and cost-effective treatments are approved in a timely manner.

Contact information by insurance companies

Cigna

• Cigna prior authorization form
• (800) 882-4462 

Medicare

• Medicare prior authorization form
• Find out what Medicare health plan covers your drugs  

United Healthcare

• United Healthcare prior authorization form

Community Health Options

• Community Health Options prior authorization form

Humana

• Humana prior authorization form
• After filling it out, patients can fax the form to (877) 486-2621. 

Anthem

• Anthem prior authorization form
• (844) 912-1226 

Aetna

• Aetna prior authorization form
• Contact information for providers 

How Local Infusion handles prior authorization

Local Infusion's dedicated guides are highly experienced in working with various insurance providers, patients, and physicians. This, in concert with a digitally-streamlined process, helps to get patients through the process as efficiently as possible, oftentimes weeks faster than through other sites of care.

Within hours of a physician referral, our team will reach out and digitally onboard patients — a quick process that takes less than two minutes.

We then work with providers, patients, and insurance providers to ensure that the authorization submission is as complete as possible, to increase the chances of a speedy approval. Regular updates are shared with providers and patients as the process progresses so no one is in the dark.

READ MORE: Prior Authorization: What Is It & How Long It Takes