Insurance Authorizations - It's on YOU!

Five Day Plan for Insurance Authorizations and Ig Therapy

We’ve all been there, haven’t we? Insurance needs to authorize our infusions. Or maybe you haven’t. Maybe your physician, nurse, or some other blessed soul has taken care of all of this for you. Consider yourself one of the fortunate few, but do remember that this post exists, because you WILL need it someday…

One of the things I find most frustrating in discussions around insurance is how reluctant most people are to take ownership of the process. You know who cares most that you/your child actually infuse on time? YOU! It doesn’t matter to your insurance or your specialty pharmacy if your treatment is delayed or denied. They aren’t the ones who need the treatment, are they? I don’t think most of them would act so dismissively if it was their immunoglobulins on the line.

I’ll be honest. I’m REALLY annoying when it comes authorization time. But you know what? I’ve not had to delay infusion because of insurance issues and I’ve been infusing for 13 years across almost that many insurance plans. How do I do it? Here’s a step by step of my most recent process to demonstrate my process.

Day 1

  1. Call your insurance company. Give them your HCPCS code (my medicine is J1569 - you can do an internet search for your brand and should find it) and ask what authorization is required, whether this is covered under major medical or pharmacy benefits, and who their preferred specialty pharmacy is. NOTE: ALWAYS use their preferred pharmacy if you want the easiest path to getting authorization.

  2. Call the specialty pharmacy they tell you is responsible for providing your infusions. Let them know you want to set up infusing xyz product in xyz fashion and that you need xyz authorization. Be warned - this might not be the right pharmacy. They may have to run a test claim to confirm. Ask them to run a test claim. Give them all the information they need to set you up as a new patient.

  3. If you need an authorization: call your prescribing physician’s office. Tell them you need a prior authorization for your infusion. Make sure they have your correct insurance information. They should be able to start the authorization process with that information.

Day 3

  1. Call the specialty pharmacy. Find out the status of ordering your medication and what, if any, additional information they need from you. Ask whether they have gotten in touch with your doctor’s office to provide the information they need - including the actual medication prescription.

  2. If the pharmacy says they’ve requested information from the physician, ask them what information they still need and what number it should be faxed to.

  3. Call your physician. Tell them what the pharmacy told you. Ask about whether they’ve heard anything from the insurance company regarding status of the authorization.

  4. Call the insurance company. Ask them the status of the prior authorization for your infusion medication.

Somewhere along the way on Day 3, you will find someone needs some information from one of the parties involved. Call that person. Let them know that someone is waiting on information from them. Let them know who is waiting and what information they need.

Day 4

  1. Call whomever needed to send more information. Find out if they’ve sent the information and, if so, when it was sent. If not, when will it be sent? Don’t worry about being a pest here. They don’t care about your infusions as much as you do, remember?

  2. Call the person who needed the additional information. Did they receive the information? Are they all set? Repeat until everyone has the information they need.

  3. If the person who needed more information wasn’t the insurance company, call the insurance company. Ask about the status. Ask if they need more information. If the authorization has gone through, ask the authorization number. They should be able to give this to you over the phone.

  4. Call the SP. Tell them you have the authorization number. Give it to them. Ask to set up your order. They will tell you they need to verify the authorization first. Offer to hold.

Day 5

  1. By this point, you should be able to order your meds. Good for you! Well done.

Obviously, this process is a very general outline of what you need to do and your mileage may vary. Give it a shot, though, and you might find the process less stressful because you have a LOT more control than you think you do. Good luck and happy infusion!

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