Prior Authorizations: How to Navigate and Speed Approvals

Prior authorizations exist for legitimate reasons, including controlling costs and preventing fraud. However, they also tend to cause delays that interfere with care. To give a few examples, should your doctor decide that a certain newer drug really ought to be prescribed for you, any time that this medicine needs prior authorization could become the time for treatment request delays ranging from days to weeks, as the insurer may even ask for additional documentation. 

That is where Beem comes in. Beem allows users to compare plans, looking for those with fewer prior authorization hurdles, quicker approvals, and streamlined prior authorization processes. According to detailed comparisons, Beem lets patients choose coverage that least impedes them.

How Does the Prior Authorization Process Work?

Step 1: Requesting Prior Authorization

The process begins when your healthcare provider submits a request to your insurance company for approval of a specific treatment, medication, or procedure. Providers typically include detailed information such as:

• Relevant medical records.
• Diagnostic test results.
• A comprehensive treatment plan explaining why the requested service is necessary.

Example: Maria, who suffers from chronic migraines, requires a new specialty medication. Her doctor submits the prior authorization request with previous treatment history, MRI results, and notes demonstrating why alternative medications were ineffective. This level of detail helps the insurer understand the medical necessity of the prescribed treatment.

Step 2: Review by the Insurer

Once submitted, the insurance company reviews the request based on established criteria. Insurers evaluate:

• Medical necessity: Does the treatment meet clinical guidelines?
• Cost-effectiveness: Is there a less expensive yet equally effective option?
• Coverage policies: Is this treatment included under the patient’s plan?

The insurer may approve, deny, or request additional information. Approval timelines vary depending on the complexity of the service:

• Routine prescriptions: 1–3 business days.
• Imaging tests (e.g., MRIs, CT scans): 3–7 business days.
• Complex surgeries or procedures: 1–2 weeks.

Step 3: Decision Notification

After review, the insurer notifies both you and your healthcare provider about the decision, providing a clear explanation of whether the requested service, procedure, or medication has been approved.

• If approved: You can proceed with treatment, confident that your plan covers it and that your financial responsibility has been clearly defined. Having this approval in hand ensures that you won’t face unexpected out-of-pocket costs.
• If denied: You have the option to appeal the decision or request further review. Understanding the reason for denial and providing any additional documentation or clarification can improve your chances of a successful appeal.

Timely communication between your provider and the insurer is crucial for avoiding unnecessary delays in care. It’s also a good practice to maintain organized records, including copies of the authorization request, approval notice, and any correspondence, so you can reference them if questions arise in the future or if additional treatments require prior authorization. Keeping a detailed record can help streamline future requests and provide clarity in the event of disputes.

Common Types of Services That Require Prior Authorization

Medications and Prescription Drugs

Some medications, especially high-cost or specialty drugs, require prior authorization. Examples include biologics, injectables, and brand-name prescriptions that have lower-cost alternatives. Prior authorization ensures the treatment is medically necessary and that the insurer is managing healthcare costs responsibly.

Diagnostic Tests and Imaging

Advanced imaging tests such as MRIs, CT scans, and genetic testing often require prior authorization. Insurers review whether the test is appropriate for your condition and whether a less expensive or equally effective alternative exists.

Example: Alex requires a CT scan for back pain. His insurer reviews his medical history and prior X-ray results before approving the CT scan, confirming it is the most suitable diagnostic tool.

Surgeries and Medical Procedures

Many elective surgeries and procedures require prior authorization for coverage. This includes procedures such as bariatric surgery, orthopedic surgeries, and certain cosmetic procedures. Prior authorization ensures that the procedure aligns with medical guidelines and is clinically necessary.

Specialty Care and Referrals

Certain specialist visits or referrals may require prior authorization, particularly in HMOs or managed care networks. This helps coordinate care efficiently and ensures patients receive the right type of specialist services while controlling costs.

Why Prior Authorizations Are Necessary, and How It Can Help You

Controlling Healthcare Costs

Prior authorizations help control overall healthcare spending by verifying that treatments are medically necessary. This reduces unnecessary tests, repeated procedures, and overprescribed medications, ultimately helping maintain lower premiums for all members.

Example: A patient may be referred for an MRI for knee pain. Prior authorization confirms that a prior X-ray and physical therapy were insufficient, ensuring that the MRI is truly required before approval.

Reducing Fraud and Abuse

Insurers use prior authorizations to prevent fraudulent claims and ensure prescribed treatments are legitimate. This layer of oversight protects patients from unnecessary or potentially harmful interventions.

Better Quality of Care

Prior authorization allows insurers to evaluate whether the proposed treatment is the most effective option. In some cases, alternative treatments may be safer, more cost-effective, or better suited to your condition.

Example: Patients with chronic back pain may be guided toward physical therapy before considering surgery, improving outcomes and reducing risk.

How to Speed Up the Prior Authorization Process

Step 1: Understand Your Insurance Plan’s Prior Authorization Requirements

Review your plan handbook or online portal to know which services require prior authorization. Understanding the rules in advance helps prevent delays.

Tip: Beem can help you compare plans with fewer prior authorization requirements, allowing you to select coverage that minimizes waiting periods.

Step 2: Communicate Effectively with Your Healthcare Provider

Ensure your doctor submits a complete request with all necessary medical records, diagnostic results, and treatment history. Missing or incomplete documentation can significantly delay the approval process.

Tip: Ask your provider to follow up with the insurer regularly to ensure your request is processed efficiently.

Step 3: Stay Organized and Track Requests

Maintain a record of all prior authorization requests, submission dates, and communications with the insurer.

Tip: Set reminders to follow up with your insurer if you haven’t received a decision within the expected timeframe.

Step 4: Utilize Electronic Health Records (EHR)

Electronic submissions are faster and less prone to errors than paper requests. Confirm that your provider is using EHRs to submit requests, which often speeds up approvals.

Step 5: Consider Alternative Therapies That Don’t Require Authorization

If you need care quickly, ask your provider about treatments or medications that can be approved immediately. This can help you avoid delays while waiting for prior authorization.

Example: John needs an MRI for knee pain. His provider submits the request electronically and follows up with the insurer, resulting in approval within three days, rather than the typical two weeks.

What to Do if Prior Authorizations Are Denied

Step 1: Review the Denial Letter

Carefully read the denial letter to understand the reason for rejection and any missing documentation.

Step 2: Appeal the Decision

Most plans allow for an appeal. Work with your provider to submit additional evidence supporting the medical necessity of the treatment.

Step 3: Consider a Peer-to-Peer Review

Some insurers allow a direct discussion between your provider and an insurance medical professional to justify the treatment. This often leads to faster reconsideration.

Step 4: Seek External Support

If internal appeals fail, you can contact your state insurance department or request an independent medical review to challenge the denial.

How Beem Helps You Navigate the Prior Authorization Process

Beem’s platform simplifies the process by helping users:

• Compare health plans with fewer prior authorization requirements.
• Find insurers with faster approval times for medications, tests, and procedures.
• Make informed decisions to reduce delays in care.

Mini Case Study: Lisa, a patient with chronic migraines, uses Beem to compare plans. She selects a plan with minimal prior authorization requirements for specialty medications. This ensures timely access to treatment, avoiding unnecessary delays.

Conclusion

Understanding prior authorizations is key to preventing delays in care. Knowing which services require approval, submitting complete documentation, and tracking your requests can save time and reduce stress.

Beem acts as a catalyst for informed decision-making. By comparing health plans, users can select coverage with fewer authorization hurdles, faster approvals, and better alignment with their healthcare needs. Start exploring your options today with Beem and take control of your healthcare journey, minimizing delays and ensuring timely access to the care you need. Download the app here.

FAQs for Prior Authorizations: How to Navigate and Speed Approvals