Your Guide to Navigating Prior Authorization

Prior authorization can be a speed bump in your inflammatory bowel disease (IBD) treatment journey. Or it can stop that journey in its tracks and send you and your care team in a new direction.

Either way, the process—established by health insurance companies to manage their costs—can lead to treatment delays and denials for people with IBD. Let’s take a look at the ins and outs of prior authorization and how to navigate it.

What is prior authorization?

Prior authorization means your provider must ask your insurance company for approval before you undergo a specific test or procedure or use a new medication. Without approval, the insurance company will not cover the costs.

Many years ago, insurers only required prior authorization for new or expensive medications. However, they have expanded prior authorization to include many common tests, procedures, and drugs, including generics.

Prior authorization rules vary among insurers and often change. The process can be complicated and time-consuming for your doctor’s office, involving multiple electronic requests, phone calls, and faxes. Insurance companies ultimately grant the vast majority of preauthorization requests, but they don’t always make it easy, and it may take a few days or even weeks.

When you need prior authorization for medical care

You may already be familiar with the experience of waiting for an insurance company to approve a prior authorization request. Typical scenarios for people with IBD include the following:

• Your current medication is not providing symptom relief, and your doctor wants to prescribe a biologic/biosimilar. But before the pharmacy can process your prescription, the insurance company requires documentation to confirm your current medication isn’t working. 
• Your doctor wants to assess inflammation in your bowel and orders medical imaging. The insurance company maintains a less expensive imaging test would be just as effective and requires documentation from your doctor justifying the need. 
• You need surgery to relieve an obstruction, fistula, or other complication of your IBD. Rather than immediately getting you on their schedule, the surgeon must work with your care team to submit documents proving the surgery is medically necessary. 

How to obtain prior authorization

If you need prior authorization, your doctor’s office will process the request for you at no charge. They will follow up with your insurance company until the request is approved or denied. This process can involve a great deal of back and forth. For example, many documentation requests from the insurance company are complicated and involve many steps. Your doctor may be unable to tell exactly what information the insurer is looking for, leading to multiple phone calls for clarification and assistance.

The prior authorization process can range from a day or two to a few weeks.

Why insurers deny prior authorization requests

Health insurance companies deny prior authorization requests for many reasons, including:

• Administrative errors, such as using an incorrect term or misspelling a name 
• Concerns about cost 
• Concerns that the medication, test, or treatment isn’t medically necessary
• Ineligibility, meaning that your plan doesn’t cover the drug, test, or procedure
• Missing paperwork 

What to do after a denial

If the insurance company denies the request, your doctor can file an appeal with the insurer. If the appeal fails, you still have options. The first step is to talk with your doctor. Is there an alternative drug, test, or procedure that could work just as well? If not, you can ask your insurance company to reconsider the denial. If your insurance is provided by your employer, you can speak with your HR department and find out if they have resources that might help.

The Crohn’s & Colitis Foundation offers a variety of sample letters/templates you can download and customize to help with your appeal. Work with your doctor’s office to ensure you have all the necessary documentation.

Not sure where to start? Ask our IBD Help Center

Learning how to manage your healthcare costs and navigate your insurance coverage is challenging for anyone with IBD. But it can help you feel more in control and stay on track with your treatment.

The Crohn’s & Colitis Foundation is here to support you. Contact our IBD Help Center for personal answers from our knowledgeable information specialists. 

• Call the free helpline (1-888-MY-GUT-PAIN). 
• Send us an email at [email protected].
• Text chat with a live agent (when available). 

Our agents can help you understand your insurance coverage and connect you to other helpful resources. This service is available in more than 170 languages.