How to Obtain Prior Authorization

We need to consider the following steps to obtain prior authorization before providing services or sending prescriptions to the pharmacy:

• First important thing is to check with insurance company or plans policy documents or formulary (Which you may see this information on particular insurance websites), whether any of your Medical service or Prescriptions requires authorization. By this we can prevent the Medical service claim denials and will ensure that the pharmacy will not be delayed in filling a prescription due to unmet prior authorization requirements as well as prevent medication non adherence.
• When you find that the Prior Authorization is needed for the service, then start locating the process for submitting the request (Most of the insurances need doctors to fill the Prior Authorization form located on the insurance web portal when you are faxing or mailing the request).

Below are the methods or options to obtain prior authorization:

1. Standard Electronic Transactions (ePA)

Standard Electronic Prior authorization also called as automated prior authorization. It is a standard process used across health plans where we can submit Prior Authorization request electronically. Where available, integrates directly with EHR enabling healthcare professionals to easily obtain prior authorizations.

Disadvantages: Standard electronic transactions are solutions integrated into the EHR work flow are not widely available and also response may not be in real time, due to manual health plan processing and review.

2. Payer Portal

This method often consumes less time than manual process (Fax and Phone), because all the required information presented in one place.

Disadvantages: Since it is outside of EHR/eRX workflow, the information from EHR must be re-typed onto web forms and also only few health insurance company support via portal most required forms to be faxed.

3. Fax

Fax is the most widely available method to obtain prior authorization.

Disadvantages: It consumes more time as forms must be filled out by hand and also confusion in selecting the correct PA form. Since it is Outside of EHR workflow, supporting documentation must be submitted manually along with prior authorization form.

4. Telephone (Check back side of the Member ID card or particular insurance website)

In this method all information can be reported at one time.

Disadvantages: Long hold and will still require supporting documentation to be faxed.

5. Secure Email

Enable submission of necessary information as email attachment and it’s encrypted for security.

Disadvantages: Health plans generally don’t support this method, potential delays as a result of additional information requests and also it cost to practice for this method.

• Ensure that the prior authorization submitted according to the plan guidelines along with supporting documentation and medication history to support medical necessity and to indicate any prior care that has been provided to the patient. By following this protocol it helps to prevents delays and leads to speed up the approval process.
• Ensure to follow up regularly to prevent delays due to lack of information and make sure to submit the requested information to Health Insurance Company on time for approval.

If Prior Authorization disapproved incorrectly or for missing data, appeal the decision along with missing data or supporting documentations.