How to Quickly Move a Prior Authorization Case Through the Approval Process

Prior authorization is the method by which your insurance company determines whether or not a particular medication should be covered and, if you get a rejected claim at the pharmacy, it can often create gaps in your medicinal therapy or delay the start of it. In any case, "coverage review" (as it is sometimes called) may be an inconvenience at best, but there are several things you can do to speed the process along.

Finding out that you need a prior authorization.

Very likely you'll first know that your medicine requires prior authorization when your pharmacy is unable to process a prescription. The pharmacist will let you know that they have received a message from your insurance company in the rejection notes. The note will often include a number for your prescribing doctor to contact to initiate coverage review.

Ask the pharmacist to give you the phone number for your own reference as this will keep the speed of the process under your control. If the pharmacy does not have the number ask them if they faxed your doctor's office to put in the review request. If they have, then call your doctor's office to get the phone number and also ask them if they have sent in the review request to your insurance company.

Your doctor's role in the speed of the process.

The primary factor in how quickly your case makes it through prior authorization is in the promptness of your doctor's office. The diligence of your insurance company is not a question as they are the ones who require the coverage review in the first place and, secondly, this is what the company does all day.

Your doctor's office, on the other hand, tends to feel they have matters more pressing than worrying about which medications your insurance covers. This is true, maybe, but some offices handle the process much better than others. Some doctors even staff a full time member who does nothing but interact with the insurance company to make sure therapies can start as soon as possible or so that ongoing therapies are not interrupted. Other offices toss the prior authorization requests aside to handle them "whenever".

Your job is to know which description best reflects your doctor's office. To do this, call the prior authorization number you received from the pharmacy and ask if the review has been initiated. If it has -- great -- your doctor's office is on the ball. While your insurance company is on the phone, be sure to get the case ID number so you can check the status of your prior authorization at any time.

What if your doctor has not initiated the prior authorization case?

If the prior auth agent tells you that no case has been called in by your doctor, it's time to take matters into your own hands and get the ball rolling. All you need are a few simple pieces of information:

1) The name of your medication (and any generic alternatives).
2) The strength of the medication and the quantity required. For example: Adderall XR 20 mg, 1 per day.
3) The prescribing doctor's first and last name.
4) The physical address of your doctor's office
5) The doctor's telephone number.

This is all the information the agent will need to build your prior authorization case. Any missing information will delay the process. Once the case is completed, the agent will give you a case ID number which you can use to check the status at any time.

If you are nearly out of your medication, you might ask the agent to call your doctor to complete the case by phone. This will expedite the process by taking the time issue away from your doctor's office and it allows the insurance company to process the criteria immediately instead of waiting a day or two.