Understanding Prior Authorization

What is prior authorization?

Prior authorization is a process used by healthcare insurers or managed care organizations to determine if they will cover the cost of a prescribed medication or medical service. Healthcare providers must obtain approval from the insurer before the medication or service can be provided. This process typically involves submitting documentation to demonstrate the medical necessity of the treatment.

How does prior authorization impact patients?

• It delays care, which could lead to adverse outcomes for patients.
• It complicates decision making process leading to a greater use of health care resources, resulting in unnecessary waste instead of cost savings.
• The prior authorization process is unpredictable, making navigating it burdensome for patients.