Prior Authorization Guide
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Prior AuthorizationStop waiting for insurance approval. Learn how to expedite, appeal, and win prior authorization battles.
Prior authorization denied? Learn how to get approval for medications and procedures. Step-by-step guide, appeal templates, and time-saving tactics.
Urgent Care? Request Expedited Review
If delay could harm your health, request an 'urgent' or 'expedited' review. Insurance must respond within 24-72 hours for urgent requests.
The Problem
Prior authorization (pre-approval) requirements delay your treatment while insurance decides if they'll pay. Denials hold up care for days or weeks, and in Medicare Advantage only 11.5% of denials are ever appealed (KFF, 2024), so most patients give up or pay out of pocket.
The Solution
Appealing works far more often than people expect. Request peer-to-peer reviews, submit additional documentation, and escalate through internal and external appeals. Among Medicare Advantage denials that were appealed, 80.7% were partially or fully overturned (KFF, 2024).
Common Reasons for Prior Authorization
- 1Step Therapy Required - Insurance wants you to try a cheaper medication first. Request an exception if the cheaper option previously failed.
- 2Medical Necessity Not Demonstrated - Documentation doesn't show why treatment is needed. Have your doctor submit detailed clinical notes.
- 3Out-of-Network Provider - Treatment requested from non-participating provider. Request a network exception if no in-network option is available.
- 4Incomplete Information - Missing diagnosis codes, clinical notes, or forms. Resubmit with complete documentation.
- 5Experimental/Investigational - Insurance considers treatment unproven. Provide peer-reviewed studies showing safety and efficacy.
How to Respond: Step-by-Step
Understand what needs authorization
Before any treatment, check if prior authorization is required. Your doctor's office should verify, but you can also call your insurance. Check your insurance formulary for medication requirements.
Have your doctor initiate the request
Your doctor's office submits the prior auth request with clinical documentation to your insurance. Provide your doctor with complete medical history and ask what documentation they're submitting.
Follow up actively
Don't wait passively. Call insurance within 2-3 days to confirm receipt, ask for timeline and expedited review if urgent, and request peer-to-peer review if initially denied.
Appeal denials immediately
If denied, you have the right to appeal, and most appeals succeed (80.7% of appealed Medicare Advantage denials were overturned, KFF, 2024). Note the appeal deadline (usually 30-180 days), request a peer-to-peer review with insurance medical director, and submit additional supporting documentation.
Escalate if needed
If internal appeals fail, you have external options including state insurance commissioner complaints and independent review. Request external independent review and consider patient advocacy organizations for help.
Prior Authorization Appeal Letter
Template with medical necessity arguments
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Frequently Asked Questions
How long does prior authorization take?
Standard prior authorization takes 3-14 business days. Urgent requests must be decided within 24-72 hours. If your insurer doesn't respond in time, the authorization is often automatically approved.
What happens if prior authorization is denied?
You have the right to appeal. Ask for a peer-to-peer review where your doctor speaks with the insurance medical director. Among Medicare Advantage denials that were appealed, 80.7% were partially or fully overturned (KFF, 2024), and additional documentation helps.
Can I get treatment while waiting for prior authorization?
Yes, but you may have to pay out-of-pocket initially. If authorization is later approved retroactively, you can be reimbursed. Some states require insurers to cover emergency situations without prior auth.
What is a peer-to-peer review?
A peer-to-peer review is a phone call between your doctor and the insurance company's medical director. It's often the most effective way to overturn a denial because your doctor can explain the clinical necessity directly.
Can I expedite prior authorization?
Yes. Request an 'urgent' or 'expedited' review if delay could harm your health. Urgent requests must be decided within 24-72 hours. Have your doctor document why the request is urgent.
What is step therapy and how do I avoid it?
Step therapy requires you to try cheaper medications before the one prescribed. You can request a step therapy exception if you've previously failed cheaper options, have allergies/contraindications, or there's clinical evidence the prescribed medication is necessary.