“The first time I had to get a prior authorization, I was so confused! I thought my doctor giving me a prescription was authorization. Frankly, I was intimidated by the paperwork. Now, I know that it just takes a few extra steps. I put it on my to-do list and do one step a day so it doesn’t get overwhelming.” What is a Prior Authorization?A prior authorization (PA), sometimes referred to as a “pre-authorization,” is a requirement from your health insurance company that your doctor obtain approval from your plan before it will cover the costs of a specific medicine, medical device or procedure. Many times, this involves your doctor completing a form to illustrate to your insurance company why the insulin, insulin pump or continuous glucose monitor (CGM) you are prescribed is medically necessary. Your insurance company will have requirements that need to be met before it will agree to cover the specific item or treatment. Why Are PAs Important to Understand?It’s helpful to understand the steps that you need to take to gain access to coverage for the prescriptions and treatments you use to help manage your type 1 diabetes (T1D). Each plan is different, so while one health insurance plan may not require a PA for your treatment, another plan—even one from the same insurance company—may. Check your insurance plan policy documents before starting the process to understand if a PA is required. Also, the exact content of the PA request may vary from point to point. For example, obtaining PA for a pump may involve supplying different information than obtaining a PA for a continuous glucose monitor. How Do I Get Prior Authorization for a Medication?The steps below are the main points in the prior authorization process. Every plan has a slightly different way of doing this, so make sure to check with your insurance company for those details.
Helpful Tips for How People with Diabetes Can Successfully Obtain a PA:Work togetherTake an active role and work closely with your doctor or the contact at your doctor’s office to ensure they have the needed information. They will also need key dates for submitting the requests, so be sure to share that information as well.
Be thorough
Be mindful of timing
JDRF maintains a forum where insurance issues can be discussed. Is this resource helpful? Did we miss something? Let us know! Your privacyWe value your privacy. When you visit JDRF.org (and our family of websites), we use cookies to process your personal data in order to customize content and improve your site experience, provide social media features, analyze our traffic, and personalize advertising. By choosing “I Agree”, you understand and agree to JDRF’s Privacy Policy. Who is responsible for obtaining preauthorization for patient hospitalization?In most cases, your healthcare provider will start the prior authorization if they are in-network. However, if you are using a healthcare provider that is not in your plan's network, then you may be the one responsible for getting prior authorization.
What happens if you don't get prior authorization?If you're facing a prior-authorization requirement, also known as a pre-authorization requirement, you must get your health plan's permission before you receive the healthcare service or drug that requires it. If you don't get permission from your health plan, your health insurance won't pay for the service.
Who denies prior authorization?Insurance companies can deny a request for prior authorization for reasons such as: The doctor or pharmacist didn't complete the necessary steps. Filling the wrong paperwork or missing information such as service code or date of birth.
How does preWhat is a pre-authorization? A pre-authorization is essentially a temporary hold placed by a merchant on a customer's credit card, and reserves funds for a future payment transaction. This hold typically lasts about five days, though this depends on your MCC (merchant classification code).
|