Depending on your plan, certain services and equipment may need to be approved by your insurance company before you can use them. You may need to get approval from hospitals and healthcare centers for specific inpatient and outpatient services, home health care services, and prescription drugs.
This is called preauthorization, advance authorization, or prior approval. All of these terms mean that you need authorization from your insurance company before treatment can begin. This type of health insurance plan requires prior authorization before you can use certain services, except in case of emergency.
For a preauthorization request, you need the following information:
• Your name, your health insurance policy number or member ID, and your date of birth
• The name of your medical professional, your address, and your National ID
• Information regarding your mental health (illness or condition)
• The proposed treatment plan, including any diagnosis or procedure code (your healthcare provider can help you with this)
• The date you will receive the service and the time of hospitalization (if admitted)
• The center where you will be treated
In general terms, the medical professionals who treat you take care of the preauthorization before arranging the service. However, it is always a good idea to check whether they have obtained the necessary approval or not well in advance. If your medical professionals are not in the network, they will not request preauthorization. You will need to seek approval yourself.
Beginning January 1, 2020, you or your healthcare professional may request the renewal of an existing prior authorization, up to 60 days before this authorization expires. Under your plan, certain drugs need approval from your insurance provider before they can be covered. Drugs that require prior authorization have the initials PA (Prior Authorization) next to them on the Drug List. These medications will only be covered by your plan if your doctor requests and receives approval from your insurance company.
Types of medications that commonly need approval
• Those that may be unsafe when combined with other medications
• Drugs that cost less and are equally effective available alternatives
• Those that should only be used for specific health conditions
• Those that are frequently misused or abused
How does the preauthorization process work?
For health care equipment and services, your network providers will handle the process for you. If you use an out-of-network provider, you will be responsible for contacting the insurance company and obtaining prior authorization.
Preauthorization process for medications
The doctor’s office usually handles preauthorization for medications and will work directly with your insurance company. Your insurance company will then contact you to let you know if coverage for your medication has been approved or denied, or if they need more information.
Results of your preauthorization
If you are not satisfied with the results of your prior authorization, you can request that they reconsider the decision. Or, your doctor may prescribe a different treatment or medication. In some cases, your insurance company will recommend an alternative medication or treatment to your doctor’s original prescription.