Beyond the red tape: How Prior Approval helps get the right care

We get it. You have a nagging pain in your back that just won’t go away, so you go see your doctor, who sends you for an X-ray. Unfortunately, the X-ray doesn’t show a thing, so the next step might be a CT-scan or even an MRI, and you may even have to see a specialist depending on the test results.

You think you’re all set, but then the doctor says, “We’ll call you to set up an MRI appointment after we get Prior Approval from your insurance company.”

Wait. What? You wonder, “I can barely stand up and now I have to wait for my insurance company?”

Yes, you probably do.

Community Health Options understands that getting medical care is nerve-wracking enough. First, your specialist will want a referral from your doctor. Then, you'll likely need Prior Approval for services and some prescriptions your provider offers (Prior Approvals are also sometimes called Prior Authorization, Precertification or Preauthorization).

While it might feel like your care is being delayed for no good reason, having Prior Approval is an important part of your benefits. Here's what it does for you:

• Confirms coverage up front, so you don't have any billing surprises
• Gets you the right care, at the right time, preventing prescription conflicts or treatments that aren't the right fit
• Ensures your care is backed by evidence that it works, protecting you from unproven experimental treatments
• Keeps costs in line, for you and your health plan

At Community Health Options we consider this “utilization management with heart." That means as a nonprofit insurer, we work to ensure premium dollars are spent on care with the potential to deliver the best health outcomes. Our nurses and pharmacists don't dictate care: they collaborate with providers to review and approve insurance coverage for care Members need, while guarding against care that may not help.

"No” sometimes means “Yes”

Prior Approval is designed to find the most appropriate care, so "no" doesn't always mean "no." In some cases, a denial can open a conversation with your provider that leads to more care than your doctor's first request. In one example, the Community Health Options team denied a request for a certain kind of outpatient behavioral health care. That's because as they reviewed the Member's case history, they saw a need for inpatient care and worked with the provider to deliver that higher level of care.

The utilization management team responds to urgent requests within 24 hours and strives to answer more routine requests within 72 hours. 

Procedures requiring Prior Approval can change over time. For instance, Community Health Options has dropped many requirements for PAs across three categories—ultrasounds, obstetrics ultrasounds and services related to treating fractures. A code review committee reviews these requirements on an ongoing basis and can all add a requirement, such as for elective plastic surgery or experimental treatments. 

Your right to appeal

Members and providers always have the right to appeal a Prior Approval decision, whether for a medical benefit or prescription. In many cases, more information from your doctor helps to move things along, and sometimes providers will consult an independent doctor to reach a decision. If you want to file an appeal yourself, our Member Services team can guide you through the process.

Have a question about Prior Approval or your benefits? Call the Community Health Options’ Maine-based Member Services team at (855) 624-6463 between 8 a.m. and 5 p.m., Monday through Friday.

Note that in-network providers will file Prior Approval requests on behalf of Community Health Options Members. Members using out-of-network providers should call Member Services to find out whether a procedure requires Prior Approval or Notification. See your plan documents for more details. 

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