prior authorization

Posts Tagged: prior authorization

Why Did my Health Insurance Deny My Claim!?

No! You expected your health insurance to cover a service, and then you get the dreaded letter that it’s been denied. Why do claims get denied and when does it actually matter (that’s right, sometimes it doesn’t matter)?

Your health plan might refuse to pay for a service or treatment you received for many reasons. It’s good to know whether it was denied because of the services themselves OR because of how your provider submitted it. Why is this important? Because in the first case, you’ll probably be responsible for paying the claim. In the second, you won’t be.

Here are some common reasons claims get denied where you could be responsible:

  • You didn’t get a referral or prior authorization when it was required
  • The service isn’t covered by your plan
  • You already used up your benefits for the service (like a cap on the number of physical therapy visits per year)
  • You went out of network when you have an HMO
  • Your insurance wasn’t effective at the time of the service

Don’t confuse these situations with those where a claim (or a portion of a claim) was denied because of how your provider submitted it to your insurance. This happens surprisingly frequently.  It might be that:

  • Your doctor didn’t submit the right billing code to your insurance plan
  • Your doctor didn’t submit the claim in the timeframe your insurance required
  • The service was actually covered as part of another claim or set of services
  • The claim is a duplicate that was already paid

You might see these things show up on your EoBs, or Explanation of Benefits–the statements you get from your health plan just informing you about your coverage (the ones that say “This is Not a Bill”). Just know that if your provider made a mistake submitting a claim, or your insurer found that it had already been paid for, you’re not responsible!

So before you panic, look into the reason for the denial. And if you believe you were billed unfairly for the cost, you can always appeal the decision. All health plans have to honor a process of reviewing claim appeals from their members.


Making Sense of Drug Formularies

Every year, prescription drug plans seem to become more and more complicated. The question is no longer “Is my drug covered?” but how and when it’s covered. Going generic is not the only strategy to lowering your drug costs. Understanding your formulary will also help you budget, make smarter decisions, and save money.

A formulary is the list of drugs your health plan covers and the level of coverage for each. It should be sent to you with your plan documents or available online.  So what’s in a formulary? You’ll probably find some of these features:

Drug Tiers

Formularies divide the drugs that are covered into tiered categories. The higher the tier, the more expensive the drug. Tier 1 usually includes generic and low cost drugs; Tier 2 can include some more expensive generics and preferred brand name drugs (those where the insurer has been able to negotiate a discount with the drug supplier). Tier 3 includes non-preferred brand name drugs, and Tier 4 has the most expensive, specialty drugs.

It’s common for equivalent or similar drugs to appear in different tiers, so if your doctor prescribes a medication on Tier 2 or 3, ask if there is a Tier 1 version of it. Formularies are not the same across health plans—every insurer has a different list. So if you are shopping for new plans, be sure to check formulary coverage for each.

Prior Authorization

Some plans require authorization from your doctor before they cover a drug. This means your doctor will need to call, fax, or complete an online request before you fill the prescription. Sometime your doctor will also need to provide evidence that lower cost versions of the drug will not work for you given your health condition, or that you have tried other versions and had adverse effects. It can take one to three days for an authorization to be approved.

Step Therapy

Step Therapy is a process where you are required to try a lower cost version of a drug first, before the plan will pay for a more expensive version. The insurer will only cover the drug that is subject to Step Therapy if you find you do not react well to the low cost version.

Quantity Limits

Just like the name suggests, this rule means the plan will only cover a certain number of refills or a certain dosage of a particular drug over a period of time. A common quantity limit rule is only allowing refills every 30 days. If the quantity limit is a problem for you, your doctor can ask the insurer for an exception.

Finally, if you’re having issues with the cost of a medication because of one the plan features above, talk to your doctor about different drugs to try. Remember, doctors don’t usually know what’s on your formulary or what your plan covers. If a drug is too expensive, or your plan changes the cost for it, don’t assume your doctor knows or that you are stuck paying for it.


Getting The Most Out Of Your Health Insurance Plan

Health plans certainly come with no shortage of rules. And you’ll want to be sure to follow them in order to get the most out of your coverage.

1) Find the freebies.

If you joined your health plan on or after September 23, 2010, you can get many preventive care services free of cost. Yes, that means no co-pay or coinsurance, even if you have not met your deductible.  This includes services such as cholesterol and diabetes screenings, women’s exams, osteoporosis tests, STI (sexually transmitted infection) counseling, immunizations, smoking cessation evaluations, depression screening, many screenings for children, and more. For a complete list, visit

Even if you were enrolled in your health plan prior to September 23, 2010, the plan may still offer the same preventive care benefits, so it is worth investigating.  Check out the “Your Plan” tab in your Simplee dashboard to see details of what your plan offers.

In addition, many plans also offer benefits such as discounts on gym memberships, weight-loss programs, or vitamins. After all, most everything that keeps you healthy and away from the doctor will save both you and your plan money in the long run.

2) Use your network.

If you have an HMO or PPO, your plan contracts with a network of providers. You are probably already aware that seeing physicians within the network will save you money. But plans may also contract with network hospitals, labs for blood tests, medical supply companies, home health providers, or imaging centers. Checking to see if these providers are a part of your plan before going to them for services can also save you money.

And after you have received the service, make sure to check your claim over on Simplee to make sure that you were properly charged.

3) Plan around the deductible.

Many plans have an annual deductible. For example, if your deductible is $500, you must pay $500 out of pocket for your medical care before the plan starts paying for any covered services. If you reach your deductible during the year, it may save you money to take care of any other health needs you have that year, before your deductible renews. Or if you know you will be incurring a number of health expenses that will put you over your deductible, you may want to plan them to fall within the same deductible year so you do not end up needing to meet the deductible twice. If for example you have a calendar-year deductible and you are planning a series of procedures, you may want to avoid scheduling the first in December, in case they lapse into January.

Also keep in mind that some plans may have a separate deductible for in-network providers than for out-of-network providers—you might be starting from zero if you go out of network, even if you’ve already met the in-network deductible.

4) Ask about your drugs.

Every health plan has a formulary, or list of drugs that are covered. Formularies often divide drugs into tiers, or different levels of coverage: For example, a tier 1 drug may have a $35 co-pay while a tier 2 drug has a $10 co-pay. Doctors often have no way of knowing the level of coverage for a drug on your plan when they are prescribing it. Before filling a prescription, you can check the level of coverage with your plan. If it falls on a more expensive tier (or is not covered at all), ask your doctor if there is a similar or equivalent drug you can take which might have better coverage.

5) Understand utilization management.

Many plans now use a process called “utilization management,” where certain procedures must have prior-approval from the plan before they are covered. You should find out if your plan has such requirements. If so, always make sure you have gone through all the steps to get a service authorized before you receive it. Usually, it is up to your doctor’s office to contact your insurance company to start the utilization review, but it is ultimately your responsibility to make sure it gets done.

Above all, the best way to get the most out of your plan is to understand the rules. Every health plan is different. Sometimes, the rules can even be different for two people with the same plan, depending on when each of them joined. You can view all the details about your specific plan when you log in to your Simplee account. If you have any additional questions, call the plan—it’s best to know so you don’t get that surprise bill later on.