GBS Advocacy
Insurance Insights
Do I Need Pre-Authorization
We often deal with claims issues when services are denied. One of the first things we do is check if a pre-authorization was done and investigate its details. We know that many people find this process confusing—like when you need one, who should do it, and how to understand it when you get it back. We’re here to help you understand this process and avoid expensive mistakes.
Common procedures that usually require a pre-authorization:
Hospital Admissions
Surgery (especially elective ones)
Advanced Imaging (e.g., CT, MRI)
Certain prescription medications
Durable medical equipment (e.g., wheelchair, prosthetics)
Specialized Treatment (e.g., chemotherapy, radiation therapy)
Consult Your Healthcare Provider
Your healthcare provider usually knows if a pre-authorization is needed for a procedure or treatment. However, it’s important to check with your insurance company to be sure. Most providers can handle the paperwork for pre-authorization and submit it to your insurance. If your provider submits a pre-authorization, you’ll get a copy of the decision by mail or through your Member Portal. Review and understand this decision carefully. We’re here to help you with this process. Remember, pre-authorization doesn’t guarantee payment. If your provider changes any codes, the new or additional codes may not be covered.
Check with Your Insurance Carrier
Being aware of your benefits and any potential exclusions can help you avoid unexpected costs and ensure you’re well-prepared. Your insurance carrier can give you an estimate of the procedure’s cost, including co-pays, deductibles, and other fees. They can also verify that the doctors and facilities involved are within your network. Additionally, they can confirm if a pre-authorization was completed and discuss the results with you, providing a copy if needed. It’s crucial for members to understand their benefits and ensure all necessary steps are taken, so make sure to do your due diligence.
Leave Appropriate Time To Complete Your Due Diligence
In the event of a medical emergency, you do not need to complete a pre-authorization. However, for non-emergency situations, it is crucial to follow the pre-authorization process carefully. If your situation is urgent but not an emergency, your provider can submit an expedited pre-authorization request. We recommend waiting for the carrier’s decision before proceeding with your services. Appealing after services have been rendered is possible but extremely challenging, and the risks involved are significantly higher.
Why Does Your Insurance Carrier Require a Pre-Authorization?
Insurance companies require pre-authorizations to confirm that the procedure is medically necessary. Your provider (or you) will be responsible for providing the carrier with supporting documentation and a thorough narrative so that they have the needed evidence to determine medical necessity. The original pre-authorization can often be returned to the provider requesting more detailed information or additional supporting documents. It is crucial that these requests are returned by the deadlines given to avoid a default denial.
Appeals Process
If your pre-authorization request is denied, inquire about the appeals process. The denial notice will specify the reasons for the carrier’s decision. You and your provider should appeal if you can demonstrate that the criteria for denial can be met. Follow the carrier’s appeal process and provide the necessary explanations and documentation they require. If your situation requires an appeal, we can provide you additional details to navigate the appeals process.
If the total cost of your service without insurance exceeds your financial comfort zone, we strongly recommend obtaining a pre-authorization, regardless of whether it is required. If your provider is unwilling to assist with the pre-authorization, you can contact member services for your carrier or involve our GBS Advocacy team for support.
Experimental Treatments and Exclusions
Insurance companies rarely (almost never) cover policy exclusions or experimental treatments. It’s important to verify with both your healthcare provider and your insurance company that the proposed treatment plan does not include any exclusions or experimental treatments. If it does, be aware that the likelihood of a denied claim is very high.
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