What is Preauthorization?
Health plans may require your doctor to get approval before they will pay for certain medical treatments. This process of advance approval is called preauthorization.
Timelines for Preauthorization
When a health plan gets a request from a doctor to provide a treatment that requires preauthorization, it has three days to review the request and decide whether the suggested treatment or services are medically necessary and appropriate.
Inpatient Facility Requests
If the suggested treatment or services are to be given in a health care facility, your health plan must review the request and make a decision within 24 hours.
Your doctor or other healthcare provider can request the the renewal of an existing preauthorization at least 60 days before a preauthorization expires. Health plans must review and decide on a renewal request before the existing preauthorization expires if practicable.
Health plans must post preauthorization requirements on their websites.
- Postings of preauthorization requirements must include a list of the healthcare services that require preauthorization.
- Changes to preauthorization requirements must be given to you before the changes take effect.
Timelines for Appeals
Appealing Denied Requests
If your health plan doesn’t think the suggested treatment or services are necessary and denies the request, then you, your doctor, or someone acting on your behalf can appeal the decision for your health plan to reconsider.
If the denied health care services are for emergency care, continued hospitalization, prescription drugs, or intravenous infusions, you can ask for an expedited appeal of the decision and it has to be resolved within one working day from the date the health plan gets all the information they need.
If your appeal is denied, you can ask for a review of the health plan’s decision by an independent review organization. The review organization must make its determination in several days, depending on the seriousness of your condition.