“A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.” –Healthcare.gov
It’s a big, technical-sounding word. For most people, a preauthorization is not necessary and won’t ever come up during treatment. But for others, a preauthorization may be necessary for a variety of reasons: transplants, new medical or biomedical technology, new surgical methods or techniques, and more. You can check your health plan for a list of what types of treatments require a preauthorization .
What is a preauthorization?
Essentially, a preauthorization is a safeguard, an extra step to ensure you’re receiving the proper care. As a health insurance company, WPS doesn’t pay benefits for health care services that are experimental, investigative, or not medically necessary. This is true of most health insurance companies. A preauthorization is also a tool to ensure the appropriate use of certain drugs and allows your insurer to determine if a drug meets the medical necessity requirements of your policy.
How to get preauthorization
If you need a medical service that requires a preauthorization, you typically have to get your health care provider to fill out a preauthorization form. If you or your doctor are ever in doubt of whether or not a service will be considered medically necessary and therefore covered, it is always a good idea to have your doctor send in a prior authorization as a safeguard. Medical records describing your condition and prior treatments, FDA-approved labeling for the requested treatment, published and peer-reviewed scientific literature, and/or evidence-based guidelines can all be submitted for review as well. At WPS, we’re pretty thorough! We want to make sure you’re getting the best care available.
Once all the information is submitted, response times can vary depending on your insurer. At WPS, we’ll notify you and your doctor of the decision as to whether the service or drug is covered within 15 days.
What happens next?
If your services or drugs are approved and authorized, you’re all set!
If it is determined that the service or drug isn’t covered or medically necessary for your illness or injury, then no benefits will be paid under your policy. If you have a WPS health plan, you and your doctor will receive a clear, written explanation about how that decision was made. If you and your doctor disagree with that decision, you’re still able to get the service or purchase the drug at full retail price and appeal the decision.
How do I appeal?
Well, that depends on your health plan. If you have a WPS plan, instructions for appealing the decision usually come with the explanation for why your service or drug wasn’t approved. You can always call your Member Services Representative, check out your health insurance policy, or use the grievance form on the company’s website to file an appeal or grievance for a preauthorized coverage decision.
So that’s it! Preauthorization is a safeguard. It’s to ensure you’re really getting what you need for your illness or injury. After all, your health is in the best interest of everyone involved: you, your providers, and your health insurer.