Physician, Prescriber or Pharmacist

A health Insurance claim form and stethoscope on a desk.

The Claims Process

Finding claim forms

There are several ways to access the claim form(s) you and your patient may require to prepare and submit a prior authorization claim.

If the claim form is not available on the payer’s website, the patient may have to contact the payer directly and provide the group policy number and their certificate number or log in to their insurer’s portal.

If there is a PSP for the drug then the PSP may be able to help find the appropriate claim form. You can find links to insurers and their publicly accessible prior authorization claim forms under Resources on this site. Drug Access Canada also provides access to prior authorization forms for private payers. 

Submitting a claim for review and approval

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 your 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 drug access navigator (DAN) at the hospital where your patient is receiving treatment.

If any further information is required by the payer, you or your patient 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 your patient’s prior authorization claim is provided to avoid lengthy delays. If your patient’s drug is approved for reimbursement, your patient will be notified directly, usually by mail.

Will the approval for my patient’s prescription need to be renewed?

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 you to provide supporting information at specific times during the treatment process to continue reimbursement.