Understanding Prior Authorization

Prior authorization is an authorization process that requires Medicaid or a health insurance company to approve certain medications, treatments, or medical services before you receive them. This step helps manage costs and ensures that care is necessary, but it can lead to delays.

For family caregivers, prior authorization can be frustrating when trying to get a loved one the care they need. Medicaid beneficiaries may face challenges if a request is denied or takes too long to process.

What is prior authorization?

Prior authorization is when a doctor must get approval from Medicaid or an insurance company before a prescription drug, treatment, or medical service is covered. This process is meant to prevent unnecessary or expensive care. Insurance providers, including Medicaid, use prior authorization to confirm that treatment is a medical necessity and follows the health plan's guidelines. If prior authorization is not granted, Medicaid will not cover the cost, leaving caregivers to figure out the next steps.

How prior authorization works in Medicaid

For Medicaid beneficiaries, the prior authorization process starts when a doctor, pharmacy, or health care provider submits a request for approval. This request includes medical records, test results, or other documents to show why the treatment or medication is necessary.

This approval process can take days or even weeks, depending on the request and Medicaid's response time. Delays can happen if paperwork is missing, Medicaid needs more information, or there are long processing times.

Types of services and treatments requiring prior authorization

Medicaid often requires prior authorization for certain medical treatments, medications, and equipment. While the exact list varies by state and Medicaid plan, typical examples include:

• Prescription medications – Brand-name prescription drugs when a generic is available, specialty medications, or expensive treatments (e.g., biologics for autoimmune diseases).
• Medical procedures and surgeries – Some non-emergency surgeries, advanced imaging (like MRIs and CT scans), and specialized treatments.
• Durable medical equipment (DME) – Wheelchairs, oxygen supplies, hospital beds, and other durable medical equipment.
• Home health services – In-home nursing care, therapy, or personal care assistance beyond basic Medicaid coverage.
• Long-term care services – Assisted living, nursing home stays, or in-home care programs like Structured Family Caregiving.
• Therapies – Physical, occupational, and speech therapy beyond a certain number of visits.

Prior authorization roles and responsibilities

The health care provider (doctor, pharmacy, or medical supplier) is responsible for initiating and submitting the prior authorization request to Medicaid or the health insurance plan.

They provide medical records, test results, and justifications to show why the treatment, medication, or service is a medical necessity. Medicaid or the insurance company then reviews the request, and either approves, denies, or asks for more information.

The patient and their caregiver's role is to follow up and stay informed throughout the process. While they don't submit the request themselves, they may need to:

• Ask the provider if prior authorization is needed before a service or prescription.
• Check on the request status with the provider or Medicaid.
• Gather medical history or past approvals to support the request.
• File an appeal if Medicaid denies the request.

If Medicaid denies an authorization request, patients and their caregivers have the right to appeal the decision. The denial letter will include a reason for the decision and instructions on how to appeal.

The first step is to request a reconsideration, where additional medical records or doctor's notes can be submitted. If the authorization denial is upheld, caregivers may request a formal hearing. If needed, a Medicaid caseworker or legal aid service may provide guidance on the appeal process.

What to do if prior authorization is denied and the appeal is unsuccessful

If Medicaid denies prior authorization and the appeal is not successful, there are still other options to explore:

Ask about alternative treatments or medications

• Doctors may be able to prescribe a different medication that does not require PA or is covered under Medicaid.
• For treatments or procedures, ask if there is a similar approach that Medicaid will approve.

Request a discount or payment plan

• Some pharmacies, hospitals, and providers offer discounts for patients paying out of pocket.
• Many drug manufacturers have patient assistance programs that provide free or lower-cost medications.

Check for other Medicaid or state programs

• Some states have waiver programs or exceptions for specific conditions.
• Medicaid-managed care plans may offer case management services to help caregivers find alternatives.

Look into charities and nonprofits

• Organizations like GoodRx, NeedyMeds, and PAN Foundation help with medication costs.
• Disease-specific nonprofits may assist with treatments, equipment, or home care.

Explore a second appeal or exceptions process

• Sometimes, Medicaid may allow an additional appeal or reconsideration request if new medical evidence is available.
• If the decision was based on missing information, the provider may be able to resubmit the request with stronger justification.

Caregivers should talk to the doctor, pharmacist, or a Medicaid caseworker to find the best alternative when PA is not an option.