Get the facts: My prior authorization request wasn’t approved. Now what should I do?

• Finding out your prior authorization request wasn’t approved can feel discouraging, but you still have options, including appealing your health plan’s decision.
• Start by reviewing the letter from your health plan to understand why your request wasn’t approved, and work with your doctor’s office to understand the next steps, which could include sending additional information to your health plan and setting up a peer-to-peer call.
• UnitedHealthcare is working to improve and streamline the prior authorization process, including by transitioning to electronic processing of prior authorization requests. Because of that transition, we now approve nearly half of all requests in real-time, and almost all decisions are made within 24 hours.

If you or a family member has ever been diagnosed with a serious condition or undergone a major surgery, you know what a stressful experience it can be. Not only do these kinds of health challenges bring uncertainty, but they also leave patients trying to figure out how to manage a complicated care plan. That’s one of the reasons why prior authorization often causes frustration for patients – it can feel like yet another hurdle in an already complex and confusing process.

Fortunately, the prior authorization process is something you most likely will never experience since it’s used rarely. For most UnitedHealthcare members seeking care, prior authorization is not needed 98% of the time.¹ But if you’re preparing for a medical procedure or surgery and find out that the prior authorization request your provider submitted wasn’t approved, read on for more information about the steps you can take.

If your request isn’t approved, it can feel discouraging – but you still have options. The two most important things to know are:

• You can appeal your health plan’s decision.
• Your doctor will most likely manage most of the interactions with your health plan on your behalf.

As a first step, carefully review the letter from your health plan to understand why the prior authorization request was not approved. Next, reach out to your doctor’s office to discuss your interest in filing an appeal and to confirm who will submit the appeal to your health plan – you or your doctor’s office. Then work with your doctor’s office to understand if additional information needs to be submitted to your health plan to encourage them to reconsider the decision.

In some cases, the health plan needs additional information that specifies that the care to be provided is clinically appropriate, medically necessary and covered by your health plan.

• To demonstrate medical necessity, it can help for your doctor’s office to outline the clinical standards they’re relying on to justify use of the surgery or procedure they’re recommending as part of your care plan.
• Clinical standards are authoritative guidelines developed through a comprehensive review of research on treatment options for medical conditions, including the evidence showing how successful those treatment options are.
• Clinical standards also reflect the consensus of experts in a particular field of medicine.
• They’re intended to help care providers make decisions when diagnosing and treating various conditions. 

It’s also a good idea to submit any prior test results that justify the care your doctor is recommending as well as evidence of any prior treatment options you’ve tried that failed to adequately address your illness or condition.

If your doctor’s office is filing the appeal on your behalf, confirm what information they will submit to your health plan and if any information from your perspective should be submitted as well. And keep in mind you may need to sign a consent form. If you will be filing the appeal, work with your doctor’s office to gather the records and documentation you’ll need to submit along with your appeal forms. And be aware of the deadline to file your appeal, which is typically 60 to 180 days from the date when your plan notified you that your prior authorization request was not approved. The denial letter from your insurer will include this information.

As the last step in the process of filing your appeal, ask your doctor’s office if your doctor plans to request a peer-to-peer conversation with your health insurance company. This is an important step in the appeal process as it gives your doctor a chance to explain directly to a doctor who works for your health insurance company why he or she feels the recommended care plan is evidence-based and clinically appropriate. Taking advantage of this opportunity to speak one-on-one with a doctor from your health plan and answer questions can often make a meaningful difference in the outcome of your appeal.

If waiting could put your health at risk, you can request an expedited review so a decision is made more quickly — typically within 72 hours.

In some cases, you can request an external review of your prior authorization request by an independent third party, who will review your case and issue a final decision.

Ultimately, if the independent third party agrees with your health insurer and your requested treatment is not approved, you should talk with your doctor about your options. In some cases, an alternative care plan could be appropriate for your condition.

Prior authorization plays an important role in keeping care safe and affordable, and it’s one of the most effective tools to protect people from unexpected out-of-pocket costs. But regardless, at UnitedHealthcare, we know prior authorization can be a frustrating process for patients and providers and can feel like an unnecessary complication in their care journey. Check out this article to learn more about our commitment to not only making the process faster, simpler and more transparent but also to reducing our requirements so that prior authorization is used only when it truly protects patients and improves care.