Prior authorization: prescription to approval

Interviewer: So I want to understand prior auth, soup to nuts. Pretend I just started in your office and I have no idea what you actually do all day. Where does it start?

Coordinator: [laughs] Oh, where does it start. Okay. It starts with the doctor. The provider sees a patient, decides they need something — a medication, an MRI, an infusion, a surgery, whatever — and they put that order into the chart. That's the moment. To them they're done, they prescribed the thing. To me, that's when the fun begins.

Interviewer: Because not everything just goes through.

Coordinator: Right, exactly. So the first thing I do is figure out — does this even need a prior auth? Because plenty of stuff doesn't. So I look at the patient's plan, and I check the drug or the procedure against the payer's rules and their formulary. And here's the first thing people don't get — there's two totally separate worlds. There's the pharmacy benefit, which is drugs you pick up at the pharmacy, and there's the medical benefit, which is stuff we administer here — infusions, imaging, procedures. They go to different places, different rules, sometimes a different reviewer entirely. So step one is really, which bucket is this, and does this bucket require an auth.

Interviewer: And if it doesn't?

Coordinator: If it doesn't need one, beautiful, the patient just goes and fills it or we schedule it and I move on with my life. But if it does — and the expensive stuff almost always does — then I'm off to gather documentation.

Interviewer: What does gathering documentation actually mean?

Coordinator: It means I'm digging through the chart. I need the notes, the diagnosis codes, labs, any imaging. And the big one — what have they already tried? Because a huge amount of these come down to what they call step therapy, "fail first." The payer wants to see that you tried the cheap drug and it didn't work before they'll pay for the expensive one. So I have to document, like, "patient was on metformin, didn't control, then we added this, still didn't work" — that history is the whole ballgame a lot of the time.

Interviewer: Okay, so you've got the package. Then you send it off?

Coordinator: Then I submit it, yeah. And ideally I'm doing that through the payer's electronic portal — the ePA portal — because it's faster and I can actually track it. But I'll tell you, in 2026, I am still faxing. I am still on hold on the phone with some plans. There are holdouts who want a fax, and I want to scream, but that's the job.

Interviewer: A fax. In 2026.

Coordinator: A fax. In 2026. [laughs] Anyway. So it goes to the payer, and the first thing on their end is intake — they log it and they do a completeness check. Did this office include everything we need? And this is the first place it can bounce.

Interviewer: Bounce how?

Coordinator: If it's incomplete — I forgot an attachment, a field's blank, they want a specific lab value I didn't include — they kick it right back. And then I'm re-gathering and resubmitting. So that's the first loop. You don't want to get kicked back, because every kickback is days. But it happens.

Interviewer: Say it's complete. Then what?

Coordinator: Then it goes to actual clinical review. And depending on the benefit, that's either a UM nurse — utilization management — or a pharmacist, and they take my request and hold it up against their coverage criteria. Medical necessity, the step therapy thing we talked about, what formulary tier the drug's on, quantity limits, units. They're basically checking, does this tick every box in our rulebook.

Interviewer: And if it ticks every box?

Coordinator: If it's a clean, simple one — it just sails through. Auto-approved, sometimes almost instantly on the portal. Those are the good days. But the ones I actually spend my time on don't sail through. Those get what they call a pend.

Interviewer: A pend.

Coordinator: Pending. It means the reviewer's not saying no, but they're not saying yes — they want more. So they send back a request for additional clinical information. And guess where that lands? Back on my desk. So that's another loop — I go get whatever they're asking for, send it back in, and it re-enters review. Sometimes that's enough and it clears. Sometimes it's not, and that's when it gets escalated to the big one.

Interviewer: Which is?

Coordinator: Peer-to-peer. So now the documentation back-and-forth has stalled out, and the only way through is the prescribing physician actually gets on the phone with the payer's medical director — doctor to doctor — and makes the case for why this patient needs this thing. And honestly that's often where a stuck case finally breaks loose, because it's a real conversation instead of a form. The catch is getting two busy doctors on a phone call at the same time. That's its own little nightmare to schedule.

Interviewer: Okay. So eventually a decision comes down.

Coordinator: Eventually, yeah. The determination. And it's one of three things. Approve — great. Deny — not great. Or partial, which people forget about — they approve it, but not how you asked. Like, "we'll cover three months not twelve," or "we'll cover forty units not sixty." So you got a yes, but a smaller yes.

Interviewer: And then everybody gets told?

Coordinator: Everybody gets notified — us, the patient, and the pharmacy if it's a pharmacy drug, so they know they can fill it. And then it forks on the outcome. If it's approved, the patient goes and fills the prescription, or we schedule the procedure, and that case is basically closed. If it's denied — then we're not done, we're just getting started. That's the appeal ladder.

Interviewer: Walk me up the ladder.

Coordinator: So level one is a reconsideration — I basically resubmit, but with a stronger case, more documentation, really hammering the medical necessity. If that doesn't work, level two is a formal appeal, often with another peer-to-peer attached. And if we burn through all of that and they're still saying no, there's an external review — an independent outside reviewer who's not the payer, and their call is binding. That's the last resort, but it exists, and sometimes you win there precisely because it's not the insurance company grading their own homework.

Interviewer: And once something's approved — you're actually done? Like, done done?

Coordinator: [laughs] No. No, no. Because every approval comes with an expiration date and a number of units or visits. So it's good for, say, six months, or twelve infusions, whatever. And the second that runs out — or the patient burns through the units — and they still need the therapy? The whole thing starts over. I'm back to gathering docs and submitting all over again for the re-auth. So it's not a line, it's a circle. The good ones come back around.

Interviewer: So what's the thing people get wrong about all this?

Coordinator: Honestly? People think a denial means no. Like, the patient gets the letter, it says denied, and they just... stop. They abandon the therapy. And that's the tragedy, because a denial is so often not really a no — it's a "you didn't give us enough" or "you didn't try the cheap thing first" or "nobody picked up the phone for the peer-to-peer." A huge chunk of denials get overturned on appeal. But the process is so slow and so opaque and so full of faxes and hold music that people give up before they get there. The drug's sitting right there, approvable, and the patient walks away because the system wore them down. That's the part that actually keeps me up. The work isn't really the paperwork — it's not letting people quit before the yes.

Interviewer: That's the place to end it. Thank you.

Coordinator: Yeah. Anytime. Now if you'll excuse me, I have a fax to send. [laughs]