Why would a drug need prior authorization?
Here are some of the reasons we require prior authorization for a drug:
What if my prescription requires prior authorization?
First, you or your pharmacist should talk to your doctor. There may be another drug you can take that doesn't need prior authorization. If not, you can start the approval process by calling the number on the back of your Blue Cross ID card.
How do I know if a prescription requires prior authorization?
You can use your plan's drug list, also called a formulary. Start by finding your plan here. Then look for a PA after the name of your prescription. You might find this article helpful: How do I read a drug list?
How they work
Prior authorization and pre-claim review are similar, but differ in the timing of the review and when services may begin. Under prior authorization, the provider or supplier submits the prior authorization request and receives the decision prior to rendering services.
Benefit to Providers and Suppliers
In an effort to reduce provider burden, these initiatives don’t change any medical necessity or documentation requirements. They require the same information that is currently necessary to support Medicare payment, just earlier in the process. This helps providers and suppliers address claim issues early and avoid denials and appeals.
Does Medicare Require Prior Authorizations?
Beneficiaries with Original Medicare ( Part A and/or Part B) generally do not need to obtain a prior authorization form for most Medicare services, such as doctor’s visits, hospitalizations, diagnostic studies or treatments.
How Does Medicare Prior Authorization Work?
Prior authorization works by having your health care provider or supplier submit a prior authorization form to their Medicare Administrator Contractor (MAC). They must then wait to receive a decision before they can perform the Medicare services in question or prescribe the prescription drug being considered.
How Do I Get a Prior Authorization From Medicare?
Prior authorization is most common with prescription drugs. In most cases, you will not have to fill out a prior authorization form yourself, as your doctor’s office or pharmacy will typically file the request on your behalf .
When Is Prior Authorization Required?
Generally speaking, Original Medicare beneficiaries are free to see specialists visit out-of-state doctors without getting prior authorization, as long as those doctors and providers accept Medicare.
The Reason for Medicare Prior Authorizations
Prior authorization can help protect a beneficiary’s rights to covered Medicare benefits, and it can also act as a means of reducing improper billing, waste and fraud within the Medicare system. It also helps to cut down on over-utilization of unnecessary care.
Get More Help With Prior Authorization
If you have further questions about Medicare prior authorization forms, filing a Medicare claim or how Medicare will cover a certain service or item, you can call 1-800-MEDICARE (1-800-633-4227). You may also contact your local State Health Insurance Assistance Program for help.
When will OPDs be exempt from prior authorization?
Those hospital OPDs will be exempt from submitting prior authorization requests for dates of service beginning May 1, 2021. More information on this process can be found in the Operational Guide and the Frequently Asked Questions below.
What is the CMS 1717-FC?
Through the Calendar Year 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule ( CMS-1717-FC ), CMS established a nationwide prior authorization process and requirements for certain hospital outpatient department (OPD) services. This process serves as a method for controlling unnecessary increases in the volume of these services.
What is prior authorization?
Healthcare.gov defines prior authorization as “approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan”. The general process has many names including precertification, pre-authorization, prior approval, and predetermination.
Why is prior authorization important?
It is also be important to have good documentation policies. If a prior authorization requires step therapy in its criteria, each trial will need to be documented.
How long does it take for chemo to be approved?
The process can take weeks to complete.
What happens if you don't get a prior authorization?
Additional miscommunications can happen when trying to initiate or submit the prior authorizations. These result from either pharmacists or doctors not starting the requests, fax machine malfunctioning, or having difficulties getting a person on the phone.
What is formulary in insurance?
The formulary includes the list of medications that are covered under an insurance plan. This process is needed not only to ensure minimizing prescription costs, but also to verify that what is being prescribed is medically necessary and appropriate for the patient.
Can a physician recommend a treatment plan?
The physician can also recommend an alternative drug or service that is covered by the patient’s health insurance plan. In some cases, an insurance company may require patients to start on a less costly medication or service. This is to see if the patient sees results or has a need for more costly therapy.
Can cancer progress?
Cancer can progress and change rapidly. Any delay in treatment may change the intended treatment plan or outcome and result in medication nonadherence. For someone battling cancer, the last thing they should have to worry about is the cost of their potentially life-saving medication.
