It is incumbent on the payer to provide a clear written explanation to the plan member or patient as to why the prior authorization claim has been denied. The patient will be able to pass this on to their prescriber, patient support program (PSP) or drug access navigator (DAN) who can decide on next steps. They may:
There are also other resources for patients listed below:
A plan member or patient who is communicating with a payer directly regarding prior authorization is unlikely to be familiar with the language used by those who work with prior authorization claims on a day-to-day basis. They may also be under significant emotional stress because of concerns regarding whether or not they will be able to access to their prescribed drugs, whether any cost to them will be affordable, time and income lost from work, or concerns about their long-term prognosis.
Providing plan members or patients with information in plain language and recommending that they reconnect with their physician, PSP, or DAN on next steps is an important part of communicating a claims denial.