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If your request for prior authorization has been denied, you have the right to know why. You can ask your healthcare provider's office, but you might get more detailed information by asking the medical management company that denied the request in the first place.
The Prior Authorization Process Flow The healthcare provider must check a health plan's policy or prescription to see if Prior Authorization is needed for the prescribed treatment. The healthcare professional must sign a Prior Authorization request form to verify the medical necessity claim.
If your prescription requires a prior authorization, the pharmacy will notify your healthcare provider. Your provider will give the necessary information to your insurance company. Your insurer will then decide whether or not to cover your medicine.
To the insurer: ? Patient name, date of birth, insurance policy number, and other relevant information. ? Physician and facility information (eg, name, provider ID number, and tax ID number) ? Relevant procedure and HCPCS codes for products/services to be provided/performed.
Tips to consider: Keep track of appeals and how long until an insurer must make a decision. Leverage a payer's peer-to-peer process. Speaking with the insurer's medical director or other physician available to speak with physicians about prior authorization issues can clear up problems much faster.