Prior Authorization

If you have ever been told by your pharmacy or your provider that your medicine or referral/imaging procedure requires a “Prior Auth” before they can proceed, you may have felt confused and frustrated.

We wanted to share with you the complex process this can for your provider be to help you to better understand.

A prior authorization (prior auth) is a requirement by your health insurance plan to obtain approval for specified medical services such as certain

  • Prescription medications
  • Diagnostic imaging,
  • Physical therapy
  • Medical equipment.

Without this approval, the medical service will not be covered by your insurance. And sometimes prior auth requests are denied by the insurance company.

SRMG handles prior auths for our patients – usually for new prescriptions and imaging.

See the example below of a typical prior auth process for a medication (please note that the process varies from patient to patient and can be different for each person/situation).

Your provider prescribes a new, brand name medication for you, or it may be a medication you have been on chronically, but you have changed insurance plans and now have different pharmacy benefits. 

  1. The prescription is sent to the pharmacy
  2. The pharmacy runs your claim through your insurance and the claim is rejected because a prior auth is needed
  3. The pharmacy contacts SRMG to let us know (this is sent through fax)
  4. SMRG contacts your insurance on your behalf to request the prior auth through multiple ways depending on your prescription plan. Typically this is submitted through your chart to your insurance carrier. (we may need to call you to gather for more information)
  5. When SRMG receives approval of your prior auth. If the prior auth is denied, we work with your SRMG provider and you to appeal the denial or to find an alternative medication for you that your prescription plan will cover.

This process with your insurance company can sometimes take days to complete.  This can be because your plan is requiring more information to validate the need for the medication.

Please be assured that SRMG’s prior authorization team is working hard for you behind the scenes to help you get the medicine or care that you need as quickly as they can.

Note:  Most insurance plans also require a prior authorization for high-end diagnostic imaging. Please contact your health plan directly for specific details.

PRIOR AUTHORIZATION FAQ

  • Formulary change: when your plan decides that there are alternative medications they will cover- they will require your provider to show proof that you have tried the alternative medications that they do cover.
  • A high-tier medication: your plan may offer to cover a lower tier if one is available
  • Exclusions: when your insurance company no longer covers the medication your provider prescribes
  • Quantity: when your insurance plan will only allow a certain quantity of medication – additional quantity may only be covered if considered medically necessary by your plan

  • Plan requires the patient to have a trial and failure of their preferred and covered medications first
  • If a medication is excluded, the plan no longer covers that medication
  • Medication quantity or dose exceeds the max allowed through your health plan

  • You can call the member services number listed on your insurance card or go to their website to confirm which medications are covered without a prior auth on your health plan
  • If it has been more than 4 days since your medication claim rejected at the pharmacy, please call SRMG or log into your patient portal and request to speak with our prior auth team.
  • Please be sure to have your current pharmacy benefits available (or know who your pharmacy benefits go through) and know the name of the medication that rejected at the pharmacy
  • Please be patient. We work with your insurance company and progress can be limited by their processes and guidelines

  • Patient or SRMG provider can request an appeal
  • Appeal process begins – and can take 48 hours to 60 days with your health plan
  • Insurance company sends final decision letter to your provider as well as the patient

Note:  Most insurance plans also require a prior authorization for high-end diagnostic imaging. Please contact your health plan directly for specific details.

4 tips for easing Prior Authorization

  1. Don’t get surprised — Ask  your doctor “Does this usually require prior authorization?”
  2. Keep what works — Did this letter work last time? Then keep it on file for next time!
  3. Stay a step ahead — If you know you’ll need it, see if your doctor can file a pre-authorization* to avoid delays.
  4. Fix what didn’t work — When prior authorization fails, there is an explanation. Use that information to file an appeal.

*filing the necessary paperwork before they even ask for it