When and How to Get Pre-Approved for Medical Care

Some people assume that if their doctor orders a test or procedure then the insurance company will automatically cover it. That’s not always true.
Generally speaking, all medical procedures must meet the rather vague criterion of “medical necessity.” Often there’s no doubt that a procedure is medically necessary. A broken arm will generally require x-rays, setting, and a cast, for instance.
But there are some big gray areas.
For example, blepharoplasty (the repair of an eyelid by a plastic surgeon) may be medically necessary in some cases and purely cosmetic in others. And then there are experimental procedures, or standard procedures used for unusual diagnoses. When do these rise to the level of medical necessity?
Going forward with medical care in the “gray area” – even when it’s ordered by your doctor – can result in the bill being declined by your insurance company. It’s not the doctor’s responsibility to make sure your insurer will cover the bill. It’s yours.
Here’s a good rule of thumb if you want to avoid that scenario: When in doubt, pre-authorize.
A few tips for pre-authorizing medical procedures:
Call your insurer first.
Explain your diagnosis and the procedure you want to have done. Ask if it’s covered or if a pre-authorization may be advisable.
Write a letter requesting authorization.
This is generally how authorizations are requested, though your insurance company may have special procedures to follow. Write a letter describing your condition in detail and explain that you want written approval for coverage of the procedure. Make sure your name and policy number are included.
Get help from your doctor.
Ask your doctor to write a letter explaining the medical necessity of the procedure in your case. Most doctors are familiar with the authorization process and willing to do this for you. The doctor may give the letter to you or send it directly to your insurer.
Include helpful information from your medical file.
Your doctor may be able to help you with this as well. X-rays, lab test results, and other details from your personal medical history can help make the case for coverage of your procedure. Include these in your authorization request.
If denied, try an appeal.
It may require a couple weeks to get a response from your insurer. If your request is denied, you are free to appeal the decision. If you weren’t able in your first request to provide any of the information mentioned above, include it now. Your appeal will generally be decided on the basis of medical necessary and the coverage parameters of your health insurance plan by a panel of doctors employed by the insurance company.