Tips for Requesting Prior Authorization from Insurance

I’ve written before about my frustrations with health insurance as a barrier to mental health treatment, particularly insurance companies’ insistence that we prove that services are “necessary” before they will agree to pay (and then deny the claim that they agreed to pay).

Sometimes, I have to contact insurance companies to request authorization before they allow me to help someone. Apparently someone who works in insurance and not mental health, who has never met my client before, knows more about what my clients need than I do. Depending on the situation, I may call or write a letter. Other times, the client contacts their insurance for authorization.

Depending on what is needed, insurers may respond to the client in a more helpful way than to me. For example, I have had clients successfully request that I be covered as an out-of-network provider due to one of my specialties – if I call the company and say, “Hey, I have no interest in contracting with you. Pay me anyway?” they would laugh me off the phone. My client, on the other hand, can call and say they are having trouble finding an appropriate in-network provider to treat them. Your insurance company is required to offer out-of-network benefits if none of their credentialed providers are available or able to help you.

All that to say – I write these tips as a psychologist who has requested prior authorization many times, but these tips can come in handy whether you are calling as a provider or as a client.

Here are the tips I keep in mind when I’m requesting authorization from insurance companies:

1. Be Assertive, Not Polite. You are not asking for a favor. As a client, you are getting approval for a service which you as a client are paying for. It’s ridiculous that you have to ask them to cover a service when you pay a premium. As a provider, you are demonstrating the necessity of services with someone who, frankly, is not qualified to disagree with you. I will note in my letters that I have the expertise to speak to what the client needs, and this is my professional recommendation.
2. Be Concise But Thorough. Get to the point quickly, but also explain the extent of the problem. Unfortunately, if the insurance company can argue that the situation is not dire enough, they will refuse to cover services.
3. Reference The Evidence Base. Yes, yes, I know, when it comes to mental health treatment, “evidence-based care” is a mixed bag at best. But insurance companies want to know that the service will “work” so that they don’t have to keep paying for treatment in the future. Mention and cite any research backing indicating that the service is appropriate. For example, some policies do not want to cover play therapy, so I have some sources on hand documenting its appropriateness and benefit for young children.
4. Use Their Language. Reference that the service is “medically necessary” and then state why. As I’ve said before, this phrase is ambiguous, but it is intended to mean that you require the treatment. For example, an ADHD evaluation is medically necessary if an individual wants to pursue medication options for their mental health difficulties because the prescriber needs an accurate diagnosis in order to know what medication to prescribe.
5. Focus On The Money. Insurance companies do not care about you, your well-being, your treatment, or your needs. “I am struggling and need help, which this service will provide” is good to mention as it documents necessity, but the insurance company cares only about their bottom line. Explain how refusing to cover a service will cost them more in the long run. For example, when justifying twice weekly therapy sessions, I will point out that higher frequency of sessions may prevent a much pricier hospitalization.

Insurance companies broke profit records in the third quarter of 2022. They make their money by not providing the service you pay for, by not giving providers money we earned for work that we did. Go get your money.