Getting Medical Pre-approval
or Prior Authorization
Health insurance companies use the prior authorization or pre-approval process to verify that a certain drug, procedure, or service is medically necessary BEFORE it is done (or the prescription is filled). This is extremely important for people to know, especially people being treated for cancer. If the service is done before the insurance plan approves it, you could be responsible for full cost, with the insurer paying nothing.
For prescription drugs
Prior authorization is often used with expensive prescription drugs. It means that your doctor must explain that the drug is medically necessary before the insurance company will cover it. The company may want you to use a different medicine or try a different one before they will approve the one your doctor prescribes. If there is reason to believe that the company’s preferred drug either wouldn’t work or wouldn’t be safe for you, you can appeal their decision. See If Your Health Insurance Claim Is Denied.
For surgery, medical procedures, treatments, or hospitalization
If you are going to be admitted to the hospital, or if you are planning any type of surgery, medical procedure, or treatment, you might want to call your insurer to make sure it does not require prior authorization.
If it does require prior authorization, your doctor will need to contact the insurance company to explain why the surgery, procedure, treatment, or admission is necessary. That is often the only way you can be sure your insurance will cover it.
For out-of-network care
You might also need to get pre-authorization before you go outside your network for care. Under most plans, members must use only the services of certain providers and institutions that have contracts with the plan. These plans may require that members choose providers from a particular list or network of providers.
When you choose to go outside the network for care, you generally have to pay more, or possibly pay for the full service with no payment from your health insurance plan. Some of these plans will pay at least part of the cost if you get approval from the plan before the visit or service (also called pre-authorization). You may be more likely to get out-of-network services covered if your plan does not offer a medically necessary service.
Do I need pre-approval if it’s an emergency?
The rules of prior authorization do not typically apply to emergencies, but there could be disagreement on what defines an emergency. If there’s any doubt, it’s a good idea to call them as soon as possible to find out about coverage.
What if I didn’t know that I needed pre-approval ?
It’s not uncommon for people to be seen in emergency rooms or hospitals that are listed as “in-network” but find out later that some of the doctors who saw them were not in network. In situations where you didn’t know (and may not have had any way to know) you can appeal the insurance company’s decision to not cover the care or service. See If Your Health Insurance Claim Is Denied. If you are unable to get them to pay, you can also try contacting the regulatory bodies that are in charge of the insurance company. (See Managing Health Insurance When Someone Has Cancer for details on this.) If appeals and regulators do not help, you can try negotiating with the doctors to get your bill lowered. See If You Have Problems Paying a Medical Bill.
If a treatment your doctor says you need isn’t approved
You may want to check with your health insurance administrator or get help from your cancer team to try and get the treatment approved. You can also ask your doctor if there is another treatment that will work as well, one which your plan is more likely to approve..
You can appeal these decisions just as you would a claim denial. You might get the health plan to reverse their previous decision.
Along with the American Cancer Society, other sources of information and support are listed below.
Getting help with insurance issues
US Department of Health & Human Services
For the most up-to-date information on health care and insurance laws and how they might affect you
Cancer Legal Resource Center (CLRC)
Toll-free number: 1-866-843-2572 (may need to leave a number for a call back)
Provides free legal information about laws and resources for many cancer-related issues including health insurance issues, denial of benefits, and government benefits
National Association of Insurance Commissioners
Toll-free Number: 1-866-470-6242
Offers contact information for your state insurance commission. You can contact your state insurance commission for insurance information specific to your state, or report problems with your insurance company
Patient Advocate Foundation (PAF)
Toll-free number: 1- 800-532-5274
Works with the patient and insurer, employer and/or creditors to resolve insurance, job retention and/or debt problems related to their diagnosis, with help from case managers, doctors, and attorneys. For cancer patients in treatment or less than 2 years out of treatment
Medicare Rights Center (for those with Medicare)
Toll-free number: 1-800-333-4114
This service can help you understand your rights and benefits, work through the Medicare system, and get quality care. They can also help you apply for programs that help reduce your costs for prescription drugs and medical care, and guide you through the appeals process if your Medicare prescription drug plan denies coverage for drugs you need
Your rights at work
US Department of Labor, Employee Benefits, Security Administration (EBSA)
Toll-free number: 1-866-444-3272
Information on employee benefit laws, including COBRA, FMLA, and HIPAA requirements of employer-based health coverage and self-insured health plans. Also has information on recent changes in health care laws. Information for military reservists who must leave their private employers for active duty can be found at: www.dol.gov/elaws/vets/userra/mainmenu.asp
*Inclusion on these lists does not imply endorsement by the American Cancer Society.
Last Medical Review: November 19, 2015 Last Revised: February 29, 2016