03/06/2025
Understanding Prior Authorizations and Insurance Denials
If you’ve ever been told that a prior authorization (PA) is required for your medication, treatment, or procedure, you might wonder what that means and why it’s necessary. Here’s what you need to know about how prior authorizations work and why they sometimes get denied.
What is a Prior Authorization?
A prior authorization is a process required by your insurance company before they agree to cover certain prescriptions, medical procedures, or treatments. It is not a decision made by your healthcare provider, but rather a rule set by your insurance plan.
When a provider prescribes a medication or orders a treatment that requires prior authorization, they must submit documentation to the insurance company explaining why it is necessary. The insurance company then reviews the request and decides whether to approve or deny coverage based on their specific policies.
Why Are Prior Authorizations Denied?
Denials happen for several reasons, most of which are determined by insurance guidelines, not by your doctor. Common reasons for denial include:
The insurance plan does not cover the medication or treatment – Some plans have specific formularies (approved drug lists) that exclude certain medications.
Alternative treatments are preferred – Insurance may require patients to try lower-cost or alternative medications (step therapy) before approving a more expensive option.
Non-medical reasons – Some medications or treatments may be considered non-essential or cosmetic under certain insurance plans.
Out-of-network provider or facility – If a service is performed by a provider or at a facility not covered by your plan, the authorization may be denied.
What Can You Do If a Prior Authorization is Denied?
If your PA is denied, this is a decision made by your insurance company, not your provider. However, there are steps you can take:
✔ Review the denial letter – The insurance company will send a letter explaining why the request was denied.
✔ Appeal the decision – You or your provider can file an appeal with additional information supporting why the treatment is medically necessary.
✔ Check for alternative treatments – Sometimes, the insurance company may cover a different medication or treatment that can be discussed with your provider.
✔ Contact your insurance company – Speaking directly with your insurer can help clarify their requirements and whether there’s a way to obtain approval.
At Trusted Hearts Aurora, we work hard to provide the best care for our patients, but insurance restrictions are beyond our control. If your prior authorization has been denied, we are happy to help navigate the next steps and explore your options.
If you have any questions, feel free to reach out to us!
Understanding Prior Authorizations and Insurance Denials
If you’ve ever been told that a prior authorization (PA) is required for your medication, treatment, or procedure, you might wonder what that means and why it’s necessary. Here’s what you need to know about how prior authorizations work and why they sometimes get denied.
What is a Prior Authorization?
A prior authorization is a process required by your insurance company before they agree to cover certain prescriptions, medical procedures, or treatments. It is not a decision made by your healthcare provider, but rather a rule set by your insurance plan.
When a provider prescribes a medication or orders a treatment that requires prior authorization, they must submit documentation to the insurance company explaining why it is necessary. The insurance company then reviews the request and decides whether to approve or deny coverage based on their specific policies.
Why Are Prior Authorizations Denied?
Denials happen for several reasons, most of which are determined by insurance guidelines, not by your doctor. Common reasons for denial include:
The insurance plan does not cover the medication or treatment – Some plans have specific formularies (approved drug lists) that exclude certain medications.
Alternative treatments are preferred – Insurance may require patients to try lower-cost or alternative medications (step therapy) before approving a more expensive option.
Insufficient documentation – The insurance company may request additional clinical information before making a decision.
Non-medical reasons – Some medications or treatments may be considered non-essential or cosmetic under certain insurance plans.
Out-of-network provider or facility – If a service is performed by a provider or at a facility not covered by your plan, the authorization may be denied.
What Can You Do If a Prior Authorization is Denied?
If your PA is denied, this is a decision made by your insurance company, not your provider. However, there are steps you can take:
✔ Review the denial letter – The insurance company will send a letter explaining why the request was denied.
✔ Appeal the decision – You or your provider can file an appeal with additional information supporting why the treatment is medically necessary.
✔ Check for alternative treatments – Sometimes, the insurance company may cover a different medication or treatment that can be discussed with your provider.
✔ Contact your insurance company – Speaking directly with your insurer can help clarify their requirements and whether there’s a way to obtain approval.
At Trusted Hearts Aurora, we work hard to provide the best care for our patients, but insurance restrictions are beyond our control. If your prior authorization has been denied, we are happy to help navigate the next steps and explore your options.
If you have any questions, feel free to reach out to us!
