How to Appeal a Prior Authorization Denial: Doctor Tips

Don’t get disheartened when you hit a roadblock with a prior authorization denial. Understanding your insurance plan is key whether you’re the patient or a medical provider. The appeal process can differ based on the insurance type, and knowing the ins and outs is crucial for a successful prior authorization.

Nowadays, many patients are often faced with the denial of prior authorization. The PA might be a great cost-effective solution for health plans by an insurance company. However, the request for this service can take up to several days or weeks. But this is not a thing to be upset about because it is a typical answer by the insurance company. So, in the case of such events, do not worry yourself because every person has a right to appeal for your PA to be approved.

Understand the appeal process before proceeding. A provider can appeal for you, but if not, you can do it yourself. The process varies by insurance plan. This guide will help you succeed in your prior authorization denial appeal.

And so in this post, we’ll guide you through the step-by-step process to make your prior authorization appeal successful.

Reasons Why Insurance Company Denies Your Prior Authorization

Why do those prior authorization requests get rejected? Prior authorization denial often occurs due to inaccurate patient info. Misspelled names or wrong birthdates can lead to 33% of claim denial. Getting those details right is vital for smooth sailing through the prior authorization process. You might think you were unlucky for getting your prior authorization request denied. But you should learn that there are several things to consider when submitting your request to health care services.

Here are some of the reasons why patients get their PA rejected.

• Submission of Inaccurate Patient Information

In 2019, CAQH (Council for Affordable Quality Healthcare) conducted a survey showcasing 33% of claim denial due to data quality, such as the patient’s misentered information like a wrong-spelled name, incorrect date of birth, and wrong health insurance ID number. These were some of the leading issues that led to the rejection of PA / medical services.

• Submission of Incomplete Information

Similar to inaccurate patient info, submitting incomplete or missing medication details or treatment justification can lead to PA rejection.

• Network Provider

Many insurance companies have network agreements with specific providers, so out-of-network care may result in a denied claim.

• Cost Management of Services

Not all health care covers services and every expense under its policies. Similarly, a study by the American Medical Association has shown that 15% of the claims were denied in 2020 due to coverage limitations. So, the less expensive treatment is more likely favored by the health insurance company.

• Requested Treatment or Apparatus Not Being Covered

A common reason for PA denial is that pharmacy benefits don’t cover the required treatments or devices. For example, a pharmacy benefit may cover the costs of drugs, but the operative equipment will not be covered. You’ll need two PAs: one for pharmacy benefits and another for medical benefits to cover the device costs.

• Procedural Errors

Errors can lead to PA rejection. For example, a non-emergency test is only paid if done after PA approval, regardless of necessity.

• Not Trying or Failing the Relevant Medication

Some insurers require patients to try less expensive medications first. For example, a migraine patient must prove ibuprofen was ineffective before trying other treatments.

• Review the Health Insurance Company’s Guidelines

Remember, each health plan has its own appeal process. Whether by letter or online portal, understanding it is key to a smooth appeal. Always follow the company’s guidelines for appeals. Some may require an appeal letter, while others may use an online portal, so review the process carefully.

Things to Consider Before Appealing to Health Care Services

Before appealing, review the patient’s contract for covered services and gather medical records to support medical necessity. While we’ve covered common denial reasons, there are still key points to consider when filing an appeal. Here are some reasons to consider before appealing to healthcare services:

• Gathering Records of Patient’s Medical History

Before filing an appeal, gather all necessary documents, including the patient’s medical record, history, diagnosis, and treatment plans.

• Collecting Clinical Evidence from Care Providers

Like the patient’s medical history, the patient must collect all the relevant documents and clinical proof before submission. This includes the previous prior authorization request, provider’s note, orders, advice, cost of treatment, and patient’s consent.

• Preparing a Compelling Draft

Lastly, developing a concise yet captivating letter is essential before submitting the appeal. It should describe to the insurance company why the required health insurance plan is critical to the patient’s treatment. It should also explain the specific reasons for denials while providing solid examples. So be sure to write a compelling letter that is describable and engaging.