Prior authorization is a process where insurance companies review prescribed medications to ensure they are appropriate for the condition. Certain medications like brand names with generics, expensive drugs, or those with age limits typically require prior authorization. Physicians must submit clinical documentation for review. Insurance verification specialists can assist physicians with the prior authorization process by determining coverage, facilitating resolutions, and maintaining documentation to help approvals be obtained faster.

1. Prior Authorizations for Medications – An Overview
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2. Many providers may have encountered the issue of prior authorization when
trying to receive payments for medications prescribed. Prior authorization is
an extra step required by certain insurance companies that need to review a
prescribed medication. They do this to find out whether it is the right
medication for the right situation. They want to make sure it is the right
medication for the right situation. Thus, insurance authorization is critical
for efficient billing and correct reimbursement. If physicians don’t obtain
prior authorization before filing their claims, the claims may not be
reimbursed or payment may be delayed.
Medications that Require Prior Authorization
Generally, the following medicines need prior approval.

3.  Brand name medicines that have a generic available. A generic medicine
contains the same active ingredient as that of a brand name drug while it
is available at a lower cost.
 Expensive medicines.
 Drugs that have dangerous side effects
 Medicines with age limits (that is certain drugs may not be covered when
the patient is over a certain age). Age limit can vary according to the
insurer.
 Drugs that may be harmful when combined with other drugs.
 Drugs used for cosmetic purposes.
 Drugs that should be used only for certain health conditions.
 Drugs prescribed for treating a non-life threatening medical condition.
 Drugs those are often misused or abused.
 Drugs not typically covered by the insurer, but said to be medically
necessary by the physician.
 Drugs that are typically covered by the insurer, but are being used at a
dose higher than the normal.
Typically the pharmacist or patient lets the physician know whether the drugs
prescribed require prior approval. Physicians can either prescribe another drug
that does not require prior approval or go on with the pre-authorization
process. However, it is better to verify the patient’s plan details to
understand the conditions specified for prior approval to correctly determine
whether the drugs prescribed require prior authorization.
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4. What to Do if Medicines Require Prior Authorization?
Once it is confirmed that the medicine requires prior authorization, the
physician must submit the pre-authorization letter according to the
instructions specified by the insurance company. The physician should
also provide some clinical information such as patient’s diagnosis or
medical reason why the preferred alternative would not be appropriate for
the patient. Failure to submit supplementary medical
notes/documentation with the pre-authorization request form may result
in delay of approval. The insurers will review the documents provided by
the physician and make a decision. The physician will receive an approval
letter if the insurer is convinced of the medical reason or else a denial
letter with the instructions for filing an appeal.
How Insurance Verification Specialists can be of Assistance
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5. Physicians can get the drugs approved faster by becoming familiar with
the prior authorization process. Busy physicians may not be able to
handle the entire prior approval process efficiently. In such a scenario,
they could consider the service of insurance verification experts who
will be responsible for obtaining documentation in compliance with
governmental and commercial payer requirements. Their responsibilities
include:
 Handling telephone and written inquiries from pharmacists and
physicians
 Determining whether prior authorization of medication coverage can be
given after screening and reviewing requests based on benefit plan
design, client specifics, and clinical criteria
 Providing information to pharmacists and physicians regarding
beneficiaries’ pharmacy benefits and drug coverage
 Facilitating resolution of drug coverage issues
 Maintaining accurate and complete documentation of all inquiries
Professional medical billing companies offer the service of these experts and
ensure accurate insurance verification and authorization for their
clients.
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6. About Outsource Strategies International
Outsource Strategies International (OSI) is a reputable medical
outsourcing solutions provider based in Tulsa, Oklahoma offering
advanced medical billing and coding solutions for hospitals,
physicians, physicians' groups, clinics and other healthcare entities.
Find more details at: www.outsourcestrategies.com
8596 E. 101st Street, Suite H
Tulsa, OK 74133
Main: (800) 670 2809
Fax: (877) 835-5442
E-mail: info@managedoutsource.com
URL: www.outsourcestrategies.com