Health Insurance 101: Navigating Appeals, Denials + Prior Authorizations
If you’ve landed on this resource, you’re probably in the process of filing a prior authorization or appeal with your health insurance, and for that, we issue a virtual hug. To help, here are the steps for properly filing an appeal to a denial and getting a prior authorization (PA) so that you can get the medications and services you need to live well with type 2 diabetes.
Take the required steps to get your meds + services covered
A prior authorization (PA) is a requirement from your health insurance company for coverage. It requires that your doctor obtain approval from your insurance before covering the costs of a specific medicine, medical device, or service. You may need a PA because a procedure is not routine, a drug isn’t on your health insurance formulary, etc.
The main steps for submitting a PA are pretty standard, but specific protocols may vary across plans. There may be times when your provider’s office handles submitting a PA for you, but if they don’t, here are the typical five steps you will take when submitting a prior authorization:
- Check your plan’s policy and formulary to see if PAs are required. Call the number on the back of your insurance card.
- Locate the process for submitting a PA on your insurance website or by calling your insurance’s customer service line. Once you’ve identified the process, gather all of the necessary forms and enlist help where you need it.
- Work with your doctor. They should be available to help you with this. You shouldn’t have to submit a PA alone! Pharmacists may also be able to help with submitting PAs.
- Ensure the PA is submitted according to your insurance’s guidelines. Work closely with your doctor’s office and know which individual handles PAs.
- Find out if the PA was approved or denied. You can call your pharmacy or doctor’s office to see if a decision has been made. Typically, you receive a letter in the mail, but that may take weeks. If your PA is denied, you can appeal the decision—more on that below.
Document, document, document!
Work closely with your doctor’s office and know which individual(s) handles PAs. Be extremely thorough, ensuring the PA form is filled out entirely and accurately. As you complete this process, keep track of all the dates, times and who you speak with at your insurance company.
It may sound tedious or even unnecessary (and it is and it should be), but documenting this could save you time and energy in the long run. Be mindful and start the PA process as soon as you find out one will be required for you to move forward with a new medication or medical service—be aware of all critical dates to help ensure success. Your insurance should stipulate what those deadlines are, such as if you need to submit and have your PA approved two weeks before a procedure.
Appeals + Denials
When you get a denial, know it’s your right to appeal.
Whether you filled out a PA or didn’t know your insurance required one, you may still face a denial, which means you can appeal your insurance’s decision not to cover a medication or service to support your type 2 diabetes management.
Officially, an insurance denial is when your insurance company notifies you they will not cover the cost of a treatment or medication. While frustrating, knowing you have the right to appeal their decision is essential. An appeal is an official request to your insurance company to reconsider their denial.
More than 50 percent of appeals are successful, so it’s an important avenue (and your legal right) to consider.
File your appeal promptly + enlist your doctor’s help
There are a few things to be mindful of when filing an appeal:
- Know all the necessary details (your insurance plan and member numbers, prescription information, DOB, etc.) and keep track of dates, times and who you speak with—names of contacts at your health insurance company.
- Ensure that your mailing address is updated with your insurance, as appeals are usually filed through the mail. Check your mail when filing for an appeal so you don’t miss any time-sensitive information.
- Remember deadlines, as there are limits to how long you can appeal after receiving a denial from your insurance. Timing is everything when it comes to insurance!
- Work with your doctor and their staff to get the necessary paperwork and a letter of support. They should be available to help with appeals. A letter from your physician is not meant to replace an appeal but supplement its effect.
Download a sample appeal letter
Find a sample letter that your doctor can send to your insurance company along with your appeal here. You can use this sample as a starting point or use the language precisely as it’s written.
Once you click on the hyperlink, you will be prompted to sign in to your Google account (if you are not already signed in). A copy of the sample appeal letter will be saved to your personal Google Drive when you click on the “Make a Copy” button.
You can edit your sample copy digitally, export it as a PDF and bring it to your provider. Once given the sign-off from your provider on this supporting documentation, you can work together to complete the appeal process. Remember, this document is only meant to support your formal appeal to your health insurance.
Send this finished document along with your appeal to make your case as strong as possible!
More resources that can help
For more help on navigating specific kinds of denials and appeals with type 2 diabetes, utilize these resources:
- Your Guide to CGM Access + Affordability
- Why Won’t My Insurance Cover a Continuous Glucose Monitor?
- How to Get Emergency Glucagon: Copay Cards + Insurance Denials
- Health Insurance—Pulling Back the Veil
Lean on Beyond Type 2 health insurance resources to strengthen your understanding of the health insurance marketplace, get answers to FAQs and learn more about how you can optimize your health insurance plan to thrive with diabetes.
Editor’s note: Information in this resource is derived from a health insurance guide originally created by JDRF, an active partner of Beyond Type 1 at the time of publication. It has been edited to suit the needs of the type 2 diabetes community.