SHAP Update and Prior Authorization Explained

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This article serves as the second installment in a series of writings focused on the development and implementation of the Student Health Ambassador Program, or SHAP. SHAP was designed to combat a lack of health literacy among college students, and ultimately seeks to act as an extension of existing healthcare education in various universities and college campuses. Interested parties can find the first installment of the SHAP article series here:

SHAP update

As stated in the previous article in the SHAP series, the first step to innovate this program was by creating a survey to send out to college students across the country. The survey was designed to focus on student’s existing knowledge of healthcare terms, asking students measure their understanding of 18 healthcare terms. Such terms included are the following: allowable charge, benefit, claim, co-insurance, co-payment, etc. As for the progress of the program, the survey has been sent out to The College of New Jersey community, and a total of seven students have responded. Of these seven students, two of them have indicated that they would specifically like to know more about the term, ‘Prior Authorization.’

So what is prior authorization?

Prior Authorization is a cost-savings feature of an individual’s prescription benefit plan that helps ensure the appropriate use of selected prescription drugs. This program is designed to prevent improper prescribing or use of certain drugs that may not be the best choice for a health condition. Prior Authorization differs by plan; however, most health insurance companies require the patient to meet certain criteria before willing to extend coverage for certain procedures and drugs. In order to pre-approve such cases, the insurance company will generally require that the patient’s doctor submit notes documenting the patient’s condition and medical history.

Prior authorization covers two topics;

  • Prior authorization covers required medications and drugs

Typically, Prior Authorization is only required for drugs with dangerous side effects, however there are a number of other reasons as to why a certain drug or medication needs pre-approval from a doctor such as:

  • Drugs that are harmful when combined with other drugs
  • Drugs that are often misused or abused
  • Drugs that should only be used for certain health conditions
  • Drugs not usually covered by the insurance company, but are said to be medically necessary by the doctor. Many different drugs can be used to treat the same condition. If a patient requires a particular medicine, the doctor must inform the insurance company that there are not any other medicines that would work in the patient.

An individual can found out if his or her medication needs Prior Authorization by going online and reviewing his or her health insurance plan’s list of covered drugs under the pharmacy and medical section of their insurance.

  • Prior authorization covers procedures

Prior Authorization may also be required to cover certain medical procedures; the three most common procedures that require this type of authorization are listed below. The most common type of procedure that needs Prior Authorization is ambulance transport that is not classified as an emergency. This does not apply to urgent transportation that would otherwise endanger the life of an individual, but only applies when services are scheduled in advanced. Outpatient, non-emergent diagnostic imaging procedures also require Prior Authorization. Procedures such as MRIs, MRAs, CT or CTA scans, and PET scans all require Prior Authorization before anything can be done to the patient. Finally, any surgeries or therapy visits required after surgery need to be approved by a doctor before they can be performed. Oftentimes this is so doctors can ensure a patient truly needs this service and is a suitable candidate in order to avoid any mishaps or negative effects. As with all health insurance plans there may be discrepancies so it is advised to look under the ‘covered procedures’ section of your plan to ensure all needed procedures will be covered.

What to expect if your medicine needs a prior authorization

There are differences that may occur with each individual’s varying health insurance plan; however, there is a standard procedure that most pharmacies follow when encountering Prior Authorization. First, the pharmacist has to enter an individual’s information into the system. If that individual’s plan requires Prior Authorization for the drug, the pharmacist is going to receive an alert and ask the patient to contact his or her prescribing doctor. His or her doctor, in turn, may need to contact the pharmacy to discuss whether the intended use of the drug is permissible on that individual’s plan. If authorization is granted, then the person’s prescription is going to be filled. If the aforementioned is not the case, then the individual has two choices;

  • He or she may still have the prescription filled by paying the entire retail costs of the drug himself or herself
  • He or she may ask his or her doctor to prescribe an alternate drug insured by his or her benefits plan (if available).

What to expect if your procedure needs a prior authorization

There may be differences among each individual’s health insurance plan, however most procedures requiring Prior Authorization follow a standard procedure. First, the physician or doctor will write a script for a patient for a specific procedure. If this procedure is not covered then the patient and their doctor will be alerted. The doctor then has two ways of obtaining prior authorization for a procedure:

  • The doctor may fill out a physical Prior Authorization form and mail or fax the request to the patient’s insurance company to have the procedure approved
  • The doctor may fill out an electronic Prior Authorization form and send in the request to the patient’s insurance company to have the procedure approved

Most Prior Authorization requests are approved at intake, however if the request is denied, more information may be required. Most Prior Authorization requests are generally made within two to five business days after the receipt of the request. In certain cases, however, the review process may take longer if additional clinical information is required to make a determination.

Are there any tools or apps available to help patients determine what exactly is covered under their health insurance plan?

Currently there are very little tools or calculators to aid an individual in gaining Prior Authorization for medications and services, however the three most helpful tools are listed below accompanied with a short review.

  • CoverMyMeds

CoverMyMeds is a free online service that allows individuals to submit and check the status of any Prior Authorization requests they have submitted electronically. While this is a great resource to check the status on any medicine or procedure a person may require, this service is limited in that only individuals who have a Humana plan can access it.

  • provides a free drug search tool on their website that allows individuals to search if their prescription medications they take are subject to any Prior Authorization restrictions. This tool is helpful in that it contains a search bar as well as every drug listed alphabetically so as to help patients locate their medications much easier than just searching for them aimlessly online. The website also lists helpful forms and links that assist patients in understanding exactly how to submit Prior Authorization requests for medications and procedures.

  • NaviNet

NaviNet is a free electronic tool that helps providers submit Prior Authorizations for any drug and is affiliated with most health plans, including Medicare and Medicaid. NaviNet helps streamline the Prior Authorization process by eliminating administrative waste, which allows patients to receive their medications much faster than the traditional process of mailing in a request or simply calling and requesting your doctor directly.

Trajectory of articles

Over the next five weeks, Ms. Gregorio will continue to report on her findings from the student surveys in order to determine which healthcare terms are most relevant to college students. Once the survey has reached 200 interested parties, she will then begin to create content for these confusing healthcare terms so as to provide verified, comprehensible information to confused college students and other interested individuals.

For more information or questions regarding the initial “Reviving Healthcare Terms” project, interested parties can contact Dr. Yifeng Hu at her email address; [email protected], or you can read about the initial project SHAP is based off of the following link:

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