Prior Authorization Denied? What to Do Next

You did what you were supposed to do.

Your doctor prescribed a medication, ordered a scan, recommended a procedure, or scheduled treatment. Then your health insurance company said no.

Maybe the message says your prior authorization was denied. Maybe the pharmacy says the prescription isn’t covered yet. Maybe the hospital calls and tells you the procedure can’t be scheduled because insurance hasn’t approved it.

Whatever form it takes, the immediate question is the same:

Now what?

First, don’t assume a prior authorization denial means the fight is over. It usually means your insurer has decided, based on its coverage rules and the information it received, that it will not authorize the care yet.

That decision may be challenged.

Here’s where to start.

What is prior authorization?

Prior authorization is a process health insurance companies use to require approval before they will cover certain medications, tests, procedures, treatments, or medical equipment.

Your doctor may believe you need the care. That does not necessarily mean your insurance company has agreed to pay for it.

Depending on your plan and the care involved, the insurer may want documentation showing that you meet its coverage criteria. It may require you to try another treatment first. It may decide that the requested care is not medically necessary under its policy.

Sometimes the problem is much more mundane: missing records, incorrect billing codes, incomplete paperwork, or information that never made it from one computer system to another.

The important distinction is this:

A prior authorization denial is an insurance decision. It is not necessarily the final word on whether you should receive the care.

If your prior authorization was denied, do these things first

Before you start writing an appeal, find out exactly what happened.

1. Get the denial in writing

Do not rely only on what someone tells you over the phone.

Ask your insurance company for the written denial notice if you don’t already have it. You want the specific reason the authorization was denied and the coverage rule or medical policy the insurer used to make that decision.

Look for language such as:

• Not medically necessary

• Experimental or investigational

• Out of network

• Benefit excluded

• Insufficient documentation

• Step therapy required

• Criteria not met

• Alternative treatment required first

Those phrases matter because different denials require different responses.

If the problem is missing documentation, for example, you may not need an elaborate appeal. Your doctor’s office may simply need to submit the missing information.

2. Call your doctor’s office

Tell the office that the prior authorization was denied and ask whether they received the denial as well.

Then ask a few very specific questions:

Why was it denied?

Did the insurer request additional records or information?

Can the office resubmit the authorization?

Can the doctor request a peer-to-peer review?

A peer-to-peer review generally allows your treating clinician to discuss the case with a clinician working with or on behalf of the insurance company.

That conversation can sometimes resolve a denial without requiring you to complete the entire formal appeals process.

Do not assume the doctor’s office automatically knows the authorization was denied. Insurance bureaucracy has many moving parts, and communication between them is not always graceful.

3. Call your insurance company

Use the member services number on your insurance card.

Have your denial letter, insurance card, and something to take notes with.

Ask:

What is the exact reason for the denial?

What specific coverage criteria were not met?

What information would be required for reconsideration?

Can my doctor request a peer-to-peer review?

What is the deadline for filing an appeal?

Where do I send the appeal?

Is an expedited appeal available if delaying care could harm my health?

Before you hang up, write down the representative’s name, the date and time of the call, and any reference or case number.

Keep doing this every time you speak with the insurer.

You are building a paper trail.

4. Ask for the actual coverage policy

This step is easy to overlook.

If the insurance company says you did not meet its criteria, ask for the policy containing those criteria.

For example, if an MRI was denied as not medically necessary, ask for the insurer’s medical policy governing coverage of that MRI for your condition.

If a medication was denied because another drug must be tried first, ask for the applicable step-therapy or pharmacy coverage policy.

You want to know what rule the insurer says you failed to satisfy.

Then your doctor’s office can respond to the actual rule instead of arguing with a mysterious “no.”

5. Find out whether the problem can be fixed without an appeal

Not every denial requires going immediately to war.

Ask whether the authorization can be corrected and resubmitted.

Common problems can include:

• Missing clinical notes

• Missing test results

• Incorrect procedure or diagnosis codes

• Incomplete prior authorization forms

• Failure to document previous treatments

• Failure to show why an alternative treatment was inappropriate

• Records that were requested but never received

If the denial resulted from an administrative problem, fixing the submission may be faster than filing a formal appeal.

6. If necessary, appeal the denial

If the insurer continues to deny authorization, you generally have the right to challenge the decision through an appeal process.

Read the denial letter carefully. It should explain how to appeal and the deadline for doing so.

Your appeal should focus on why the requested care meets the insurer’s coverage requirements.

Useful supporting material may include:

• A letter of medical necessity from your doctor

• Medical records

• Test results

• Treatment history

• Documentation of treatments you have already tried

• Evidence explaining why another treatment is inappropriate

• Relevant clinical guidelines or medical literature

• The insurer’s own coverage policy

Your doctor’s office may prepare much of the clinical material, but don’t assume somebody else is managing the deadline. Confirm who is doing what.

If you need a more detailed walkthrough of the appeals process, read Health Insurance Denied Care? How to Appeal in this Patient Survival Guide.

What if waiting could harm you?

If the situation is medically urgent, say so.

Ask both your doctor’s office and your insurer whether you qualify for an expedited or urgent review.

The rules and timelines depend on your insurance plan and circumstances, but expedited processes exist for situations in which waiting through the normal review process could seriously jeopardize your health or your ability to regain function.

Do not simply mark something “urgent” yourself and assume that changes the process. Ask your treating clinician whether the medical circumstances support an expedited review and what documentation the insurer requires.

If you believe you are experiencing a medical emergency, seek appropriate emergency medical care rather than waiting for an insurance appeal.

Keep everything

Create one folder.

Paper, digital, carrier pigeon. It doesn’t matter. Just keep it organized.

Save:

• The original prior authorization request, if available

• The denial letter

• Your insurance plan information

• Relevant medical records

• Letters from your doctors

• Appeal documents

• Emails and portal messages

• Fax confirmations

• Names of insurance representatives

• Dates and times of phone calls

• Case and reference numbers

After important phone conversations, write down what you were told.

If someone says, “We’ll call you back,” make a note of when they said that and when you should expect the call.

Healthcare bureaucracy has a remarkable ability to develop amnesia.

Your notes don’t.

Don’t confuse “denied” with “done”

A denial can feel enormous when you’re sick, scared, in pain, or trying to help someone you love.

It also arrives with the authority of a giant insurance company behind it, which makes the word DENIED feel considerably more final than it may actually be.

But prior authorization is a process.

And processes have next steps.

Find out exactly why the request was denied. Get the rule the insurer used. Bring your doctor’s office into the fight. Correct missing information if that’s the problem. Ask about peer-to-peer review. Appeal when necessary. Request expedited review when the medical circumstances warrant it.

Most importantly, don’t let a vague “no” be the end of the conversation.

Make them explain it.

Then decide what comes next.