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Explaining the Preauthorization Process: What You Need to Know as a Member

Do you ever feel what’s covered by health insurance is random? Wonder why one medical procedure or treatment is approved, but not another? We feel your pain. So, we asked HAP Medical Director, Dr. Robert C. Levine to explain how HAP’s preauthorization process works. Here’s what he said.

It’s not simple

I’ve been involved in the health care insurance payer systems for more than a dozen years, and I still come across issues I find confusing. It’s constantly changing. The U.S. health care system is deeply complex. As a result, it can seem like there’s more misunderstanding than understanding. The perception is we’re just throwing darts at a board. It seems arbitrary, but it’s not.

Who makes the decisions?

We’re a team of caring physicians, nurses and practitioners, such as psychologists and psychiatrists, all us of recommending what should be covered. These recommendations are based on research, science, evidence-based medical guidelines and what’s considered the standard care in the community.

We care as if we were on the other end and we needed the service. It’s one of the unique things about an organization tied to a health care system.

Why are some services covered and not others?

Preauthorization, also called prior authorization, prior approval or precertification, is how your health insurer decides if a service, treatment plan or prescription drug is necessary. This process allows for the greatest amount of a health plan’s resources to do the most good. HAP is here to improve the lives of the people we provide services for. It doesn’t mean being wasteful.

Sometimes a test gets ordered that may not be appropriate. For example, ordering an MRI for a patient who strained their back from lifting a heavy object with no other signs or symptoms may not be the most appropriate thing to do. Cost is not even presented to medical directors when we make these decisions. The patients’ needs and medical appropriateness drive our decisions.

We know it’s really frustrating when your service is denied. In the big picture, if the health plan works well, it can offer more services for more folks over a broader range when resources are used effectively.

Mismatched expectations

When patients or doctors expect A and they receive B, there’s disagreement. The decisions aren’t done in a vacuum. Does someone who’ll be walking in four weeks need a powered wheelchair? On the other hand, someone who lost the use of their legs permanently needs an electric wheelchair, and we will pay for that.

And many times, when something is not covered it’s due to the decisions made by the purchaser of the health plan, not HAP itself. For example, an employer may purchase a plan that limits physical therapy to 40 sessions in a year.

Making decisions quickly

No one wants to be told “no” or “wait” when it comes to their health. We have strict compliance requirements of when we must turn around decisions. We must provide an answer 14 days from the time a request is received by HAP.

When a member is upset, we step up immediately. Our customer service will listen and can expedite many requests. A member or doctor may request HAP expedite a request if waiting the two weeks for a decision could place the member’s life or health at serious risk.

Your rights

As a HAP member, you have appeal rights if you disagree with a denial of a preauthorization. An investigation is done on each appeal. There are physician advisors and people who are not clinicians on the appeals committee who help to decide what the best course of action is for someone who disagrees with a denial.

If you’re in a situation where you disagree with a denial of a preauthorization, call customer service at the number on your ID card. You can also log in to your account to securely talk with customer service.
Categories: Get To Know Your Plan