Prior Authorization

When your ARC care team needs prior authorization from your health plan

Depending on your medical insurance or prescription plan, certain medical treatments, diagnostic testing and imaging, or medications may require approval from your carrier before you receive treatment or care. Prior authorization confirms your recommended treatment or medication is covered by your plan. Without prior approval, your carrier may not cover the costs.

Prior authorization may also be referred to as prior approval, precertification, preauthorization, or medical necessity review.

This page should help you answer some questions about prior authorization.

Frequently Asked Questions

• Which types of healthcare services may require prior authorization?

  Examples of medical treatments and prescriptions that may require prior authorization include:

  • Medications that are potentially unsafe when taken with other medications
  • Medical treatments or medication with a lower-cost and equally effective alternative
  • Medical treatment and medication that are recommended solely for specific health conditions (surgeries, infusions, etc.)
  • Diagnostic testing and imaging
  • Durable medical equipment (DME)
  • Medical treatment and medication with high risk for misuse or abuse
  • Medications often used for cosmetic purposes
  • Home health
  • Inpatient and outpatient admissions
  • Physical therapy, occupational therapy, speech therapy
  • Select referral appointments

• How do you receive prior authorization?

  If you require prior authorization and are seeing an ARC primary care doctor or advanced practice clinician (APC), our care team will begin the prior authorization process on your behalf.
  
  If you require prior authorization and are seeing a non-ARC primary care doctor or APC, you may be responsible for obtaining prior authorization. Without approval, your treatment or medication may not be covered, and you may be responsible for some or all medical costs.

• How does the prior authorization process typically work?

  Your insurance or prescription plan provider will typically respond back within a few business days, though their response time may vary depending on the treatment, surgery, insurance plan, and other factors. During this process, they may:

  • Approve the request
  • Deny the request
  • Ask for more information
  • Recommend a more cost-efficient, but equally effective alternative before the final decision

• What if your authorization is denied?

  If your request is denied, you can always request a review or appeal from your insurance or prescription plan carrier. You can also call your health insurance or prescription plan carrier to learn why prior authorization was denied.

• What is the "No Surprises Act?"

  The No Surprises Act helps protect patients from certain unexpected medical bills. Visit our No Surprises Act page to learn more.