Getting Medical Pre-approval
Health insurance companies use the prior authorization or pre-approval process to verify that a certain drug, procedure, or service is medically necessary BEFORE it is done (or the prescription is filled). This is extremely important to know, especially for people being treated for cancer. If the procedure is done or the drug prescribed before the insurance plan approves it, you could be responsible for the full cost, with the insurer paying nothing.
For prescription drugs
Prior authorization is often used with expensive prescription drugs. It means that your doctor must explain that the drug is medically necessary before the insurance company will cover it. The company may want you to use a different medicine before they will approve the one your doctor prescribes. They may also limit how much of the drug you can have, or how many refills. If there is reason to believe that the company’s preferred drug or approved quantity either wouldn’t work or wouldn’t be safe for you, you can appeal their decision. See If Your Health Insurance Claim Is Denied.
For out-of-network and emergency care
You might also need to get pre-authorization before you go outside your network for care. Under most plans, members must use only the services of certain providers or networks of providers and institutions that have contracts with the plan.
When you choose to go outside the network for care, you generally have to pay more, or possibly pay for the full service with no payment from your health insurance plan. Some plans will pay at least part of the cost if you get approval from the plan before the visit or service (also called pre-authorization). You may be more likely to get out-of-network services covered if your plan does not offer a medically necessary service.
Also, be sure to find out what your insurance plan considers emergency care and to be sure coverage is available for certain problems that may come up.
What if I didn’t know I needed pre-approval?
It’s not uncommon for people to be seen in emergency rooms or hospitals that are listed as in-network but find out later that some of the doctors who saw them were not in network. In situations where you didn’t know (and may not have had any way to know) you can appeal the insurance company’s decision to not cover the care or service. If you are unable to get them to pay, you can also try contacting the regulatory bodies that are in charge of the insurance company. If appeals and regulators do not help, you can try negotiating with the doctors to get your bill lowered. See If You Have Problems Paying a Medical Bill.
If a treatment your doctor says you need isn’t approved
You may want to check with your health insurance administrator or get help from your cancer team to try and get the treatment approved. You can also ask your doctor if there is another treatment that will work as well, one which your plan is more likely to approve.
Check with the insurance company about how you can appeal these decisions just as you would a claim denial. You might get the plan to reverse their previous decision.
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The American Cancer Society medical and editorial content team
Our team is made up of doctors and oncology certified nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.
Along with the American Cancer Society, other sources of information and support are listed below.
Getting help with insurance issues
US Department of Health & Human Services
Website: www.healthcare.gov
For the most up-to-date information on health care and insurance laws and how they might affect you
Cancer Legal Resource Center (CLRC)
Toll-free number: 1-866-843-2572 (may need to leave a number for a call back)
Website: www.cancerlegalresources.org
Provides free legal information about laws and resources for many cancer-related issues including health insurance issues, denial of benefits, and government benefits
National Association of Insurance Commissioners
Toll-free Number: 1-866-470-6242
Website: http://naic.org/state_web_map.htm
Offers contact information for your state insurance commission. You can contact your state insurance commission for insurance information specific to your state, or report problems with your insurance company
Patient Advocate Foundation (PAF)
Toll-free number: 1- 800-532-5274
Website: www.patientadvocate.org
Works with the patient and insurer, employer and/or creditors to resolve insurance, job retention and/or debt problems related to their diagnosis, with help from case managers, doctors, and attorneys. For cancer patients in treatment or less than 2 years out of treatment
Medicare Rights Center (for those with Medicare)
Toll-free number: 1-800-333-4114
Website: www.medicarerights.org
This service can help you understand your rights and benefits, work through the Medicare system, and get quality care. They can also help you apply for programs that help reduce your costs for prescription drugs and medical care, and guide you through the appeals process if your Medicare prescription drug plan denies coverage for drugs you need
Your rights at work
US Department of Labor, Employee Benefits, Security Administration (EBSA)
Toll-free number: 1-866-444-3272
Website: https://www.dol.gov/agencies/ebsa
Information on employee benefit laws, including COBRA, FMLA, and HIPAA requirements of employer-based health coverage and self-insured health plans. Also has information on recent changes in health care laws. Information for military reservists who must leave their private employers for active duty can be found at: https://webapps.dol.gov/elaws/vets/userra/ee_disc.asp
*Inclusion on these lists does not imply endorsement by the American Cancer Society.
Cancer Legal Resource Center (CLRC). Health insurance and access to care. Accessed at https://thedrlc.org/cancer/publications-webinars/health-insurance-publications/ on May 16, 2019.
National Association of Insurance Commissioners (NAIC). Map: states and jurisdictions for consumer reference links and insurance department contact information. Accessed on May 16, 2019.
Patient Advocate Foundation (PAF). What does an approved pre-authorization mean? Accessed at https://www.patientadvocate.org/cardio-it-matters-sheets/what-does-an-approved-pre-authorization-mean/ on May 16, 2019.
US Centers for Medicare and Medicaid Services. What Medicare covers. Accessed at https://www.medicare.gov/what-medicare-covers on May 16, 2019.
US Department of Health and Human Services (State Health Care Marketplaces). Common coverage questions. Accessed at https://www.healthcare.gov/using-marketplace-coverage/ on May 16, 2019.
US Department of Labor Employee Benefits Security Administration (EBSA). Filing a claim for your health benefits. Accessed at https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/publications/filing-a-claim-for-your-health-benefits.pdf on May 16, 2019.
Last Revised: May 13, 2019
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