No prior authorization

What it means

Some plans require approval before certain services. It goes by several names: prior authorization, preauthorization, precertification, or a referral. This reason means the plan’s records show no approval for your service.

It is not the same as “prior authorization denied”. There, someone asked and the plan said no. Here, no request was made, it was made the wrong way, or the plan did not link it to your claim. Plans can require approval for some services only, so check your plan document or the plan’s list before you assume it was required for yours.

Who has to act first

Start with your provider’s office. Ask whether it requested approval, when, and what reference number the plan gave. Ask what the plan told the office about your service. Then call the plan and ask the same questions. Write down the date, the name and the reference number of every call (the call log tool helps).

Patient groups such as Triage Cancer suggest asking whether the plan will give approval after the fact, called retroactive authorization. The plan decides whether to offer that. If the plan issues a written denial, you have at least 180 days after you receive it to appeal, for a job-based plan or a non-grandfathered individual plan (check the date on your notice, which controls). Medicare, Medicaid, TRICARE, Veterans Affairs and federal employee plans have different, often shorter, deadlines.

Arguments that work

• Emergency care. A plan that covers emergency department services must cover them without prior authorization, whether or not the provider is in the plan’s network.
• Approval was impossible or risky. A plan cannot deny a claim for lack of prior approval where getting approval was impossible or could seriously jeopardize life or health. The rule’s own example is an unconscious patient.
• A request was made the wrong way. If a request reached the unit that handles benefits and named you, your condition and the treatment, the plan must tell you the correct procedure within 5 days, or 24 hours if the claim is urgent.
• The plan said none was needed. A written note, or a call record with a name and reference number, supports this. See the guide on approved-then-denied claims. In a Medicare Advantage plan, once the plan approves a service through prior authorization it may not later deny it for lack of medical necessity, except for good cause or reliable evidence of fraud or similar fault.
• The service was not on the list. Compare the plan’s list of services needing approval with what you had.
• The care was necessary. Ask the plan to review the claim for medical necessity anyway, with a letter from your doctor.

Evidence to gather

• The denial notice and the Explanation of Benefits (you).
• The plan’s list of services that need approval, with the date you looked (the plan’s website or plan document).
• Your call log with names, dates and reference numbers (you).
• Your provider’s record of any request, fax confirmation or portal message (your provider).
• Records showing it was an emergency or urgent (the hospital or your provider).
• A letter from your doctor on why the care was needed (your doctor).

What to send

Send an appeal letter that states which of the points above applies, with the supporting records and a copy of your call log. Ask your provider to send its own proof of what it requested and when. Ask the plan to reprocess the claim and to give its decision in writing.

When this is not worth an appeal

If your plan document clearly required approval, the care was not an emergency, and no one has a record of asking, an appeal has little to work with. It can only ask the plan to apply its own rules. Ask your provider whether its agreement with the plan makes the office responsible for approval, and ask the plan in writing before you pay any bill. The bill-while-you-appeal guide covers the steps.