Breaking Down What Is a Prior Authorization and How to Get It Approved
Fast
In today’s complex healthcare landscape, understanding the administrative steps behind medical care is essential for both patients and providers. One of the most common yet misunderstood processes is what is a prior authorization It can delay treatments, disrupt medication regimens, and cause frustration for everyone involved This article breaks down what prior authorization is, why it exists, and most importantly how to get it approved quickly.
What Is a Prior Authorization?
Prior authorization (PA) is a requirement set by health insurance companies that mandates providers to obtain approval before administering specific services, procedures, or medications Without this approval, insurance may deny coverage, leaving the patient responsible for the full cost.
Think of prior authorization as a checkpoint it ensures that the proposed treatment or medication is necessary and covered under the insurance plan. The provider must present clinical documentation justifying the need for care before it’s delivered.
Why Do Insurers Require Prior Authorization?
Insurance companies don’t just add bureaucracy for the sake of it Their reasons for requiring PA include:
● Controlling healthcare costs
● Preventing unnecessary or duplicative procedures
● Encouraging the use of cost-effective alternatives
● Ensuring that care meets medical necessity guidelines
While these intentions may be sound, the process is often cumbersome and can delay care significantly
When Is Prior Authorization Needed?
Not every medical service or prescription needs prior authorization However, it's frequently required for:
● High-cost brand-name medications
● Specialty drugs (e.g., injectables, biologics)
● Diagnostic imaging (MRIs, CT scans)
● Elective surgeries and non-emergency hospital stays
● Physical therapy, occupational therapy, and other outpatient services
● Medical equipment like CPAP machines or wheelchairs
Every insurance plan has its own criteria, so what requires PA under one plan may not under another.
Who Is Responsible for Getting It Approved?
Generally, the provider's office handles the prior authorization process, but patients also play a crucial role Here's how the responsibility is typically divided:
Healthcare Providers:
● Submit clinical notes, test results, and justification for the service
● Communicate with insurance for additional information requests
● Follow up on pending authorizations
Patients:
● Should verify whether a service or prescription requires prior authorization
● Provide any requested documentation (e g , previous medical records)
● Advocate and follow up with both the provider and insurer when necessary
Why Prior Authorization Takes So Long
Several factors contribute to delays:
● Manual paperwork and faxed forms
● Different rules and forms for every insurer
● Missing information that requires re-submission
● Limited staff resources in provider offices
● Delayed responses from insurance reviewers
Even minor mistakes can cause multi-day or even multi-week delays
Step-by-Step: How to Get Prior Authorization Approved Fast
Speeding up prior authorization starts with preparation, communication, and using the right tools. Here’s a proven step-by-step approach:
1. Verify Coverage Early
Check the patient’s insurance benefits before initiating treatment Confirm whether the service requires PA and if any preferred alternatives exist
2. Gather Complete Documentation
Include the following:
● Patient diagnosis
● Treatment rationale
● Previous failed treatments
● Clinical notes
● Lab or imaging results
Providing comprehensive data up front helps avoid back-and-forth with the insurer
3. Use Electronic Prior Authorization (ePA)
Many modern EHRs offer ePA features that connect directly with insurers ePA can:
● Automatically identify if PA is needed
● Prefill forms based on patient data
● Submit requests instantly
● Track status in real time
This can cut response time from days to hours
4. Use Standardized Templates
Keep pre-filled templates on hand for common PA requests These should be updated regularly to match insurer guidelines.
5. Designate a Prior Authorization Specialist
In larger practices, assigning one staff member to manage all prior authorizations can:
● Improve accuracy
● Reduce missed details
● Streamline communications
This individual should stay up to date on insurer policies and use checklists for each submission
6. Track and Follow Up
Don’t wait passively. Use calendar reminders or EHR alerts to follow up on pending authorizations. A polite but persistent call can often expedite processing.
How Long Does It Take to Get Approved?
Approval timelines vary by insurer and request type:
● Routine requests: 3–10 business days
● Urgent requests: 24–72 hours
● ePA requests: Same day in many cases
Make sure to indicate if a request is urgent due to patient risk or medication lapses
What If the Prior Authorization Is Denied?
A denial isn’t the end of the road Here's what you can do:
1. Appeal the Decision
Submit additional documentation, letters of medical necessity, or updated test results to reinforce your case
2. Request a Peer-to-Peer Review
This is a conversation between your provider and the insurer’s medical reviewer. It’s an opportunity to clarify clinical reasoning and overturn the denial
3. Consider Alternative Options
Ask the insurer what alternatives don’t require PA. Sometimes, switching to a covered generic medication or alternate treatment plan can bypass the process entirely
4. Educate the Patient
Explain the reasons behind the delay and outline potential paths forward Patients often feel less frustrated when they understand the process.
Common Mistakes That Delay Prior Authorization
Avoid these pitfalls to streamline the process:
● Incomplete or inconsistent documentation
● Submitting to the wrong insurance department
● Failing to specify the urgency of the request
● Not attaching supporting labs or test results
● Missing patient identification numbers or group IDs
Regulatory Changes and the Push for Reform
The burden of prior authorization has become a national topic of concern Both CMS and private healthcare coalitions are calling for changes, including:
● Standardized forms across payers
● Shorter turnaround times (within 48 hours)
● Transparency in denial criteria
● Automation and interoperability with EHRs
Some states have also introduced "gold card" legislation if a provider consistently gets PA approvals, they can bypass future requirements for the same services.
What Patients Can Do to Help
While the process is driven by providers and insurers, patients can take initiative by:
● Asking: “Does this require prior authorization?”
● Calling their insurer for status updates
● Checking the insurer’s portal for PA information
● Requesting alternative medications if delays are too long
● Keeping records of all communications
An informed patient is a powerful ally in speeding up approvals
Understanding what is a prior authorization and how it impacts your care is essential in today’s healthcare environment. While it may seem like an obstacle, there are proven strategies to navigate the process more efficiently. With proper documentation, electronic tools, and consistent follow-up, both providers and patients can minimize delays and ensure timely access to the care they need
In the future, industry reforms may make prior authorization faster and more transparent Until then, knowing the rules of the game is your best defense against unnecessary barriers to treatment
