In Employee Benefits, Health Insurance

green lightWho’s responsible?

Obtaining pre-authorization (or prior authorization) from your health insurance company is your responsibility. You always want to make sure that any treatment you receive will be covered by the insurance company as “In-Network”.  Not doing so can mean the treatment will be paid at the lower “Out-of-Network” benefit. Or worse, the insurance company could determine that they’re not responsible for any portion of the bill.

When do I need to get it?

Pre-Authorization is usually needed for any inpatient care and some outpatient services such as;

  1. Admission to a hospital for surgery
  2. Admission to a Rehabilitation center
  3. Genetic testing
  4. Select specialty drugs
  5. Referrals to non-participating providers
  6. Some medical devices

Do I always need it?

Not everything needs health insurance pre-authorization. Like when you visit your primary physician at the local clinic because you’re a little under the weather. Or you’re getting a flu shot and even some outpatient services don’t need prior authorization. Pre-Authorization is normally not needed for services such as;

  1. Office visits
  2. Preventive services
  3. Emergency care
  4. Select outpatient services
  5. Select tobacco cessation programs

Do I need Pre-Authorization for prescriptions?

Maybe. Sometimes this comes in the form of what insurance companies call step therapy. That means they want you to try a different medication before they authorize payment for the one your doctor prescribed. This usually happens when there’s a generic form of the medication you’ve been prescribed.
Pre-Authorization may be needed for other reasons such as;

  1. The medication isn’t listed in the Plan Formulary
  2. The doses are higher than normal
  3. Drugs for cosmetic purposes or other non-life threatening conditions

It’s your insurance – get engaged.

Being in the insurance business I see people with a very broad range of interest in their health insurance. Some people are very engaged and know exactly what things cost. Others, not so much. And it’s the “not so much” that usually end up paying more in the end. Have a great day and engage.

Recommended Posts

Leave a Comment

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Contact Us

Let's get in touch!

Start typing and press Enter to search