How To Speed Up Prior Authorization for Medication: Tips, Timelines & Approval Checklist

The period of waiting for approval of a medicine can seem like a time of time that refuses to pass. The patient's prescription is in need of attention now but the paperwork is stuck in a line between the pharmacy and the insurance company. If you have ever wondered how to speed up the process of getting medication authorization, you're not the only one. Millions of patients and clinic staff experience this same frustration weekly and the majority of the delays can be addressed through a few simple fixes. 
 

This guide explains what prior authorization is and How To Speed Up Prior Authorization For Medication works, as well as the steps you can take to receive approval sooner. There will also be coverage of the pitfalls that slow medication approvals and of the checklist that home health teams and clinics follow to ensure approvals move forward. 

What Is a Prior Authorization for Medication?

Medication prior authorization is a request a physician makes to a health insurance company before a patient receives a particular medication. The insurance company desires to see documentation of the need for the drug, the appropriateness of the diagnosis and, if needed, that cheaper alternatives have been attempted. If this approval is not obtained, the pharmacy won't be able to submit a claim to the insurance plan and the patient will end up paying the full cost of the prescription to the pharmacy. 
 

Prior authorisation is used by insurance companies to manage costs and ensure that high-risk or expensive drugs are prescribed appropriately. Common specialty drugs, brand name drugs that have generics, and some long term drugs. People are usually not aware of what a prior authorization for medication is until their pharmacist informs them that a prescription was denied, which is typically the first time they hear about prior authorizations. 

How Long Does Prior Authorization for Medication Take?

The timelines for Prior Authorization for Home Health Agencies depend on the type of medication or service requested, the completeness of documentation submitted to the insurance provider, and the insurer’s review process. Typically, a standard prior authorization request requires a response within 2–5 business days. Urgent or time-sensitive requests, when marked appropriately by the healthcare provider, are often reviewed within 24–72 hours.

However, in reality, delays do occur regularly. It can take up to two weeks or more if clinical notes are missing, billing codes are incorrect or if the fax doesn't reach the correct department. That's why many patients and providers are seeking information about ways to accelerate the time required for prior authorization because there is often a difference between the official time frame and what happens in practice. 
 

It is also useful to be aware that not all payers are created equal. Some insurance companies list average turnaround times on their provider sites, while others provide the information only when a staff member calls to ask for it. If a clinic actually logs the time each payer takes to pay, rather than relying on the printed guideline, they can make more accurate plans and have reasonable expectations that the insurer will deliver on them, rather than promising the patient a timeframe the insurer never fulfills. 

How to Submit a Medication Prior Authorization (Step-by-Step)

The fastest way to be approved will be to get it right the first time. Now let's look at the steps involved in the process. 
 

1. Get prior authorization for drugs. Review the insurance formulary or contact the insurance plan before the patient exits the office.
2. Obtain the clinical records. These are used to capture code (diagnosis), lab results, previous treatment history, and why other treatments failed.
3. Fill in the appropriate form. There are a number of common cause for rejection, including the use of the incorrect prior authorization form, each of which is specific to the payer.
4. Send via the quickest means possible. In virtually all situations, ePA is quicker than fax.
5. Track the submission. Make sure to take note of the date, time and confirmation number to follow-up if there is no response.
6. Follow up prior to the deadline. Don't be the first one to contact the insurance company. 

Common Mistakes & Challenges That Delay Medication Approvals

There's no such thing as a difficult insurance company. They result from small unobtrusive mistakes in the submission process. 

• The most common rejection is due to incomplete clinical information. A chart note without a diagnosis code, or a recent laboratory value will not be approved even if the medication is clearly appropriate. 
• Another common problem is the use of the old forms. Payers change their requirements frequently and this form may not have the field they need this year. 
• One of the more unobtrusive reasons for delay is lack of follow up. Passively waiting for a response to a request, rather than checking request status after 48 hours; does not make sense as days will be wasted for no reason. 
• Delays when denied appeal the approval. Each payer has a time period for appealing if it is not done within this time, the whole process must be repeated. 
• Another overlooked error is thinking that if the medication is denied once, it will not be covered at all. A denial in many cases simply means that they were missing one of the pieces of evidence, such as a prior medication trial or a particular lab value in a range. 

How To Speed Up Prior Authorization for Medication — 5 Proven Strategies

Below are strategies known to reduce approval times, based on industry-research-supported best practices.
 

1. Provide all papers first time. Put all clinical notes, lab results and treatment history at the front of every clinical note rather than waiting for the payer to ask for more.
2. Utilize prior authorization electronic tools. ePA platforms can save a lot of time, compared with a fax or mail, and most major payers are accepting them.
3. Identify a point person to monitor each and every request. Staff member who owns each prior authorization keeps requests from falling through the cracks.
4. Requesting medications via the phone to the payee. If you follow up with a phone call to confirm receipt and inquire about expected turnaround, you can cut down on days. 
5. Build a standing checklist for high volume drugs. If your clinic regularly prescribes a specific medication that needs approval, create a template so nothing is missing on submission.

What Should You Do When a Medication Prior Authorization Is Denied?

Denial is not the end of the world! First, read the denial letter carefully as it will indicate exactly why your request was denied. There are a few categories of most denials: missing information, a drug that needs some form of step therapy as a first step, diagnosis code mismatch. 
 

Having identified this, collect up any missing paperwork and appeal in a formal manner within the stated timeframe, typically ranging from 30 to 180 days as per the plan. The reason many appeals are successful is just because the clinical detail is included in the second appeal. If the standard appeal is denied again, inquire about an external review and request that an independent party review the case. 

Medication Prior Authorization Checklist for Faster Approval

Use this list before submitting any request on How To Speed Up Prior Authorization For Medication: 
 

• Patient demographic and insurance information confirmed and current
• Correct payer specific prior authorization form completed in full
• Diagnosis codes and clinical notes attached
• Prior treatment history and reason for current medication included
• Submission sent through ePA when available
• Confirmation number or fax receipt saved
• Follow up call scheduled within forty eight hours
• Appeal deadline noted in case of denial

Prior Authorization Should Not Slow Down Patient Care or Revenue

A day's worth of a prior authorization without resolution is a day a patient may be without needed medication and a day a clinic/home health agency waits for revenue. In a healthcare setting, delays in medication administration can impact patient care plans, hospital readmission risk and patient outcomes specifically for home health providers. When dealing with prior authorization, it's better to make it a commonplace, regular routine, and one that can be tracked, than it is to be a last minute scramble, protecting both the patient and the practice.
 

It is even more critical for patients with chronic diseases who may need to continue taking a medication indefinitely, because they may have to go without it for just a few days and lose all of the benefits of weeks of use. If a clinic treats all prior authorizations equally, even if the medicine appears insignificant, it's an incredibly good way to create a habit that will serve patients when there's a true case that can't wait. 

Frequently Asked Questions on How To Speed Up Prior Authorization for Medication

How long does prior authorization for medication take?

Standard requests typically take two to five business days. Urgent requests can be reviewed within twenty four to seventy two hours when marked time sensitive by the prescribing doctor.

What does prior authorization for medication mean?

An approval from a health insurance company for some prescriptions. The doctor should demonstrate medical need before the claim can be filed to the pharmacy. 

What do you do when a prescription is denied for prior authorization?

Please read the denial letter to determine why the denial occurred, obtain any missing paperwork and appeal the denial within the timeframe specified by the payer. Numerous denials are overturned with the supply of missing information. 

What happens if prior authorization is denied?

Read the denial letter for the specific reason, gather any missing documentation, and file an appeal within the payer's stated window. Many denials are reversed once the missing information is provided.