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There are several ways to access the claim form(s) required for a patient and their physicians to prepare and submit a prior authorization claim.
If the claim form is not available on the payer’s website, the plan member/patient may have to contact the payer directly and provide the group policy number and their certificate number or log in to the payer’s, usually their insurer’s, portal.
Links to insurers and their publicly accessible prior authorization claim forms can also be found under Resources on this site. Drug Access Canada also provides access to prior authorization forms for private payers.
Today there is no electronic mechanism in place to complete and submit prior authorization claims, therefore claim forms and supporting medical documentation must be sent to payers by mail or fax for review.
The timeline for receiving a decision from a payer on whether a patient’s claim has been approved will vary, but a wait of 7-10 days or longer is not unusual. If the drug prescribed is urgently needed, which is common for cancer drugs, then a decision may be received more quickly if the process is facilitated by a patient support program (PSP) and a drug access navigator (DAN) at the hospital where the patient is receiving treatment.
If any further information is required by the payer, the patient or physician will be contacted by mail or fax. Sometimes delays occur due to mail issues or missing faxes. Following up with the payer is important to ensure that everything required for the payer to review and decide on the patient’s prior authorization claim to avoid lengthy delays.
If the patient’s drug is approved for reimbursement, the patient will be notified directly, usually by mail.
Typically, the first prior authorization request and approval will be valid for several months and up to one year. This time varies based on the drug and will be specified by the payer.
The payer may also specify that renewals or extensions will require physicians to provide supporting information at specific times during the treatment process to continue reimbursement.
The Simplify Prior Authorization initiative is an advocate for education about prior authorization (PA) and improvement in current prior authorization practices and processes. If your organization is interested in finding out more, getting involved, or in sponsorship of this important initiative, please contact us via the link below.
