A Detailed Look at the Process and How We’re Working for You
At Allergy & Clinical Immunology Associates, we understand that waiting for care; whether it’s a needed medication, test, or procedure—can be incredibly frustrating. One of the most common causes of delays is the prior authorization process, an often lengthy and complex requirement imposed by insurance companies.
As your healthcare provider, we want to be transparent about why these delays happen, what goes into getting a prior authorization approved, and how we work behind the scenes to move things forward on your behalf.
What Is Prior Authorization?
Prior authorization (also known as pre-authorization or pre-certification) is a decision by your health insurance company that a prescribed medication, test, treatment, or procedure is medically necessary and, therefore, eligible for coverage.
It’s important to understand that this is not a decision made by your doctor; it’s a requirement enforced by your insurance provider before they agree to pay for the service. Without prior approval, your insurance may deny the claim, leaving you responsible for the full cost.
What Triggers a Prior Authorization Request?
Prior authorization is most often required for:
- Specialty medications, including biologics or newer treatments for allergies, asthma, and immunological conditions.
- Advanced diagnostic testing, such as allergy panels, skin testing, or pulmonary function tests.
- Immunotherapy and injection-based treatments, particularly if administered regularly.
- High-cost services or those with alternatives, even if the alternative may not be clinically appropriate for your condition.
Why the Process Is So Time-Consuming?
While the concept of insurance review may sound simple, the actual process is anything but. Here’s a look at what’s involved on our end:
1. Reviewing Insurance Requirements
Each insurance provider, and often each individual plan, has its own unique set of rules. What’s approved under one plan might be denied under another. Our staff must:
- Search insurer portals and medical policy databases
- Identify appropriate codes and documentation requirements
- Ensure compliance with submission guidelines
- This step can take hours, particularly when plans are vague or requirements have changed.
2. Compiling Detailed Clinical Documentation
Insurers don’t just take our word that something is necessary. They require supporting evidence, which we must gather from your medical record. This may include:
- Provider notes detailing your condition and symptoms
- Previous treatments and their outcomes
- Test results
- Explanation of medical necessity
- Often, insurers demand very specific language or forms, which we must tailor case by case.
3. Submission and Waiting
Once everything is compiled, we submit the request. Depending on the insurance company, this might be done:
- Through an online portal
- By fax
- Over the phone
- Wait times after submission vary widely. Some insurers will provide decisions within 48 hours. Others can take up to 10 business days or longer, especially for complex cases or high-cost treatments.
4. Follow-Up and Appeals
Our work doesn’t stop after submission. If a request is delayed or denied, our staff often:
- Follows up multiple times to check the status
- Participates in peer-to-peer reviews (where our physician discusses the case with an insurance company physician)
- Submits appeals or additional documentation as requested
- These steps require significant time and coordination and, unfortunately, are common even when care is clearly justified.
Why This Is Frustrating for Everyone—Including Us
We completely understand how difficult this waiting period can be for patients, especially when symptoms are disruptive, or you’re feeling anxious about your health. But we also want you to know:
This process is equally frustrating for our providers and staff.
Our clinical and administrative teams work hard to provide timely care. But we are often caught in an administrative loop dictated by policies we do not control. Our goal is always to minimize delays, but even with experience and diligence, prior authorizations are time-intensive.
What You Can Do to Help
While we handle the bulk of the prior authorization process, there are a few ways you can assist in keeping things on track:
- Please keep your insurance information up to date. If your plan, provider, or contact information changes, please share it with us immediately.
- Promptly respond to any communication from our office requesting additional forms or signatures.
- Let us know about pharmacy changes, as switching pharmacies mid-process can require reauthorization.
Our Commitment to You at Allergy & Clinical Immunology
Even though prior authorizations are outside our control, we take them seriously because we care deeply about your well-being. Behind the scenes, our staff is doing everything possible to advocate for your care by communicating with insurers, compiling records, and escalating requests when needed.
We are committed to providing transparent, diligent, and patient-centered care. At Allergy & Clinical Immunology Associates, we appreciate your patience as we complete the prior authorization process.
If you ever have questions about your prior authorization status or concerns about delays, please don’t hesitate to call our office. We are always here to help.