​How to Successfully Appeal a Medical Prior Authorization Denial for Healthcare Providers (2024)

FAQs

​How to Successfully Appeal a Medical Prior Authorization Denial for Healthcare Providers? ›

The key in an appeal is to show that the care that is being denied should be covered by the plan based on its rules, that it is appropriate, and is medically necessary. Clearly state the plan's benefits, as well as guidelines from the plan as to what constitutes medical necessity.

When appealing a medical prior authorization denial, it's crucial to provide supporting documentation that demonstrates the medical necessity of the treatment or service. This may include medical records, lab results, and notes from consultations with other healthcare providers.

Explanation: The proper response to a failure to obtain preauthorization denial is to request a retrospective review. This type of review occurs after the medical service has been provided, and it involves the insurance company evaluating the claim to determine if it meets the necessary criteria for coverage.

So, it's important to complete the pre authorization process before moving forward with treatment. If you're not in your patient's insurance network, they will need to complete the pre-authorization steps instead. Either way, you can expect the insurance company to take at least two days to approve or deny the request.

Review the reason for the denial

The first step in resolving a denied insurance claim is to understand why it was denied. Carefully review the denial notice you received from the insurance company to determine the reason for the denial.

Clarity is key

It is important to keep in mind that the appellate judges have not been involved in the previous case prior to the appeal and are therefore seeing the facts and arguments for the very first time. As a result, an effective appeal should be brief, logical, and clear.

What happens if preauthorization is denied? ›

If your prior authorization gets denied, you and your provider will get notified about the denial. You or your provider can contact the insurance for more information. Your provider can try to send in more documentation for reconsideration of coverage or change the therapy.

Provide correct and complete patient information.

One of the primary reasons that Prior Authorizations take so long to process is that incomplete or incorrect information is submitted to the health insurance provider. Take note that the smallest details matter.

If you don't obtain it, the treatment or medication might not be covered, or you may need to pay more out of pocket. Review your plan documents or call the number on your health plan ID card for more information about the treatments, services, and supplies that require prior authorization under your specific plan.

Request Denied? Try Again. If your request for prior authorization has been denied, you have the right to know why. You can ask your healthcare provider's office, but you might get more detailed information by asking the medical management company that denied the request in the first place.

When consumers challenge a healthcare service their insurer denied, they win about half the time, data from California insurance departments show.

If you want to file an appeal, ask your Human Resources (HR) administrator for more information or contact Express Scripts at the number on the back of your member ID card. In addition, Express Scripts will send you a letter that includes the reason for the denial, your appeal rights and how to file an appeal.

To successfully appeal your denial, you must provide hard evidence that mitigates every allegation in the statement of reasons. When you and your attorney provide evidence to the CAF, it will decide whether you've sufficiently refuted the claims in the Statement of Reasons. If so, your clearance will be granted.