Prior Authorization

Prior authorization (also called pre-approval, pre-certification, or utilization review) is a requirement by many insurance plans to approve certain services, treatments, medications, or equipment before you receive them. This process requires doctors, hospitals, and other treating practitioners to ask permission from the insurance company on your behalf for coverage, or you may need to pursue authorization yourself for out-of-network services. Understanding this process can help prevent claim denials and ensure timely access to needed care, and the Office of the Healthcare Advocate is available to assist both patients and providers with prior authorization requests and denials.

The Prior Authorization Process

1. Provider Initiates Request: Your healthcare provider submits clinical information to your insurance company justifying the medical necessity of the requested service, equipment, or medication.
2. Insurer Reviews Information: The insurance company evaluates the request against their clinical criteria and coverage policies. This may involve review by nurses, medical directors, or other clinical staff.
3. Decision Issued: The insurer typically issues one of five outcomes: approval, denial, request for additional information, alternative treatment requirement or denial with later approval.
4. Notification: Both you and your provider should receive notification of the decision within the timeframes required by Connecticut law.

Connecticut's Prior Authorization Rules and Timeframes

If you need emergency treatment, no prior authorization is necessary. However, you should review your health insurance plan to understand what coverage you have for emergency medical expenses and any follow-up care that might require authorization.

For Urgent Requests

• Your carrier must make a determination and notify you within 24 hours, or sooner if possible
• A request may qualify as urgent if waiting could seriously jeopardize your life, health, ability to regain maximum function, or subject you to severe pain
• Requests for treatment of substance use disorders or mental health disorders requiring higher levels of care are automatically treated as urgent under Connecticut law
• If your carrier needs additional information, they must request it within 24 hours
• Your practitioner must be given at least 48 hours to provide the requested information
• Final decisions must be issued within 48 hours of receiving the additional information

For Non-Urgent Requests

• Your carrier should make a determination within 7 calendar days after receiving the request
• For claims after you've already received services, determination should be made within 30 calendar days
• Extensions are permitted in specific circumstances: up to 5 additional calendar days for pre-service requests or up to 15 calendar days for post-service claims
• If you're asked to provide additional information, you must be given at least 45 calendar days to respond

General Requirements

• If the carrier believes filing procedures haven't been properly followed, they must notify you within 24 hours for urgent requests or 5 calendar days for non-urgent requests
• If any notice is provided orally, written confirmation must follow within 3 calendar days
• Prior authorization approvals must remain effective for at least 60 days from the authorization dateApprovals cannot be reversed or rescinded without providing at least 3 business days' notice prior to the scheduled service date

If Prior Authorization is Denied

If your insurer denies a prior authorization request:

1. Understand the Reason: Review the denial letter to understand exactly why the service wasn't approved. The carrier must provide specific reasons for the denial, reference plan coverage provisions, and explain what information would be necessary to approve the request.
2. Request Peer-to-Peer Review: If a denial is issued, your practitioner will be notified of an opportunity to request a peer-to-peer conference with a clinical peer at your carrier, provided you or your practitioner haven't already submitted a formal appeal.
3. Discuss Alternatives: Ask your provider if there are covered alternatives that might meet your needs.
4. Appeal the Decision: You have the right to appeal the denial. Remember that studies show up to 75% of appealed denials are overturned on the first appeal.
5. Request Expedited Review: If waiting could seriously jeopardize your health, request an expedited appeal.
6. Seek Assistance: The Office of the Healthcare Advocate can help navigate the appeal process and advocate on your behalf. We specialize in helping both patients and providers with prior authorization requests and denials. For providers working with patients, OHA offers guidance on the appeal process and strategies for overcoming adverse determinations.

If you are not sure were to start, request help today!