Understanding Prior Authorizations: Why They Exist — and How to Navigate Them

Understanding Prior Authorizations: Why They Exist — and How to Navigate Them

By AKG Advocacy | Helping You Get the Care You Deserve

What Is a Prior Authorization?

A prior authorization (PA) is a process your insurance company uses to decide whether they will pay for a medication, test, or procedure before you actually receive it.

In simple terms, it’s your insurance company saying:

“We want to review this first before we agree to cover it.”

Doctors and patients often see prior authorizations as unnecessary red tape — and in many cases, they’re right. But understanding why they exist (and how to navigate them effectively) can make the difference between fast approval and months of delay.

Why Do Prior Authorizations Exist?

Insurance companies claim that prior authorizations exist to:

  1. Prevent unnecessary or duplicate treatments.
    Insurers say this helps reduce waste and ensures safety.

  2. Control costs.
    By requiring approval for expensive or brand-name medications, they push for cheaper alternatives (like generics).

  3. Ensure medical necessity.
    The idea is to confirm that the treatment is appropriate for your diagnosis.

While those goals sound reasonable, in practice, prior authorizations often:

  • Delay care,

  • Create stress and confusion, and

  • Shift the burden of proof onto the patient and doctor — not the insurer.

Who Is Involved in the Process?

Several players are involved:

  • You (the patient): The person who needs the medication or service.

  • Your provider’s office: Submits the request, attaches medical documentation, and often follows up.

  • Your insurance plan (or Pharmacy Benefit Manager): Reviews and decides whether to approve or deny.

It’s important to know that you cannot file a prior authorization yourself — your provider must initiate it.
However, you can absolutely advocate and follow up to ensure it’s done correctly and quickly.  Also, you can initiate any appeals that may follow a prior authorization denial. 

How Long Does It Take?

  • Most insurance companies must respond within 72 hours for non-urgent requests and 24 hours for urgent ones.

  • In reality, many take longer due to incomplete forms, missing documentation, or repeated “fax requests.”

  • Every delay can mean days — or even weeks — without necessary care.

That’s why staying organized and proactive is critical.

Common Reasons for Denial

  • The insurer says there’s an alternative drug or therapy they want you to try first (“step therapy”).

  • The medication or treatment is not on the plan’s formulary (covered list).

  • The insurer says it’s “not medically necessary” for your diagnosis.

  • The provider used the wrong diagnosis code or forgot to include clinical notes.

Most denials are reversible — if you know how to appeal and provide the right evidence.

How to Navigate the Prior Authorization Process

1. Ask the Right Questions Early

Before your provider sends a prescription or order, ask:

  • “Does this require prior authorization?”

  • “What information do you need from me to speed it up?”

  • “Can you notify me as soon as it’s submitted?”

2. Keep a Record of Every Call

Document:

  • Date, time, person you spoke with, and summary of conversation.
    This can protect you later if there’s a dispute or delay.

  • AKG Advocacy has templates and sample documents for this step here and here. 

3. Request Copies of Everything

Ask your provider’s office for:  

  • A copy of the authorization request they submitted,

  • The reference number, and

  • The expected turnaround time.

4. Follow Up Frequently

Call the insurance company every 24–48 hours until it’s resolved. Don’t be afraid to ask for a supervisor if things stall.

5. Appeal Quickly if Denied

If your request is denied, you have the right to:

  • Request a redetermination (appeal),

  • Submit supporting documentation, like a Letter of Medical Necessity from your doctor, and

  • Ask for a peer-to-peer review if appropriate.

Tips for a Successful Prior Authorization

✅ Keep a PA Log Sheet — track dates, contact names, and responses.
✅ Save every EOB (Explanation of Benefits) and denial letter.
✅ Ask your provider to note failed treatments to show medical necessity.
✅ Use specific diagnosis codes that match the requested therapy.
✅ If your state allows, record phone calls for documentation (check one-party consent laws).

Why This Matters

Prior authorizations were meant to protect patients and the healthcare system, but they’ve evolved into barriers that delay essential care.

For people with chronic illnesses or rare conditions, delays in treatment can mean:

  • Uncontrolled symptoms,

  • ER visits,

  • Loss of independence, or

  • Permanent health setbacks.

By learning the system, keeping records, and standing your ground, you can turn a frustrating process into an opportunity to advocate effectively for yourself or someone you care about.

Takeaway

  • You have rights. Don’t be intimidated by insurance language.

  • You are your best advocate. Stay informed, persistent, and organized.

  • You’re not alone. AKG Advocacy is here to guide you every step of the way.

Always Keep Going.
— AKG Advocacy
Empowering patients. Demanding reform. Restoring hope.

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