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Beyond the red tape: Prior Approval helps get access to the right care

Apr 23, 2024
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We get it. You have a nagging pain in your back that just won’t go away, so you go see your doctor, who sends you for an X-ray. Unfortunately, the X-ray doesn’t show a thing, so the next step might be a CT-scan or even an MRI, and you may even have to see a specialist depending on the test results.

You think you’re all set, but then the doctor says, “We’ll call you to set up an appointment after we get prior approval from your insurance company.”

Wait. What? You think, “I can barely stand up and now I have to go through this red tape?”

Yes, you probably do.

Community Health Options understands that getting medical care is nerve-wracking enough, so you won’t need a referral for the specialists, even though the specialist may require one from your doctor. But Members do need Prior Approvals for certain services and prescriptions before getting treatment (Prior Approvals are also sometimes called Prior Authorization, Precertification or Preauthorization).

While it might seem like getting approval delays care, Community Health Options, as a nonprofit insurer, uses Prior Approvals to understand its Members needs and to facilitate care. Clinicians rely on evidence-based care guidelines to approve the care Members need, while protecting against the care they don’t. Importantly, approval ensures that a Member’s health plan will cover the service or procedure.

Community Health Options Chief Medical Officer Dr. Lori Tishler calls it “utilization management with heart. Our goal is to get someone what they need, so we’re constantly looking for ways to make things easier for patients and providers.”

When "No” means “Yes”

In some cases, clinicians at Community Health Options may even suggest more care than the initial request. For example, a request for a certain kind of outpatient behavioral health care was denied because the Community Health Options team saw a need for inpatient care and worked with the provider to get that higher level of care delivered.

In almost every case, the company responds to urgent requests within 24 hours and more routine requests within 72 hours, but usually less. Requests may be denied if clinicians at Community Health Options need more information about the need for a certain procedure.

And in 2023, the company dropped Prior Approval requirements for about 5,000 codes primarily across three categories—ultrasounds, obstetrics ultrasounds and services related to treating fractures. A code review committee continues to review and revise Prior Approval requirements. 

A right to appeal

Members and providers always have the right to appeal a Prior Approval decision, whether for a medical benefit or prescription. In many cases, additional information helps to move things along, and sometimes providers will talk to an independent doctor for a final decision about the best solution.

Members with questions or concerns about Prior Approval can call the Community Health Options’ Maine-based Member Services team number on the back of their Member ID card from 8 a.m. to 6 p.m., Monday through Friday.


As a proud sponsor of the event, Community Health Options was pleased to celebrate these leaders who are making a difference in our state.