Physician, Prescriber or Pharmacist

A senior couple meeting with a consultant to review insurance options and medical forms.

What To Do if the Claim is Denied

If your patients prior authorization claim for a specialty drug has been denied, they will receive written notice from their payer. You may consider an appeal for reconsideration to the payer or alternative medication. The PSP or DAN may also provide useful guidance and support on the options available to you and your patient. Below are some additional tips.

Find out the reason for denial

Encourage your patient to find out exactly why their prior authorization claim has been denied and ask for a written explanation. This can be done by contacting the payer directly.

Prior authorization drug eligibility criteria may vary between payers, as can reasons for denying reimbursement. Patients should be involved in the appeals process.

Payers are more likely to share the reason for denying the claim with a patient than a prescriber, health care practitioner or patient advocate like a PSP or DAN. A joint call with the payer representative, the patient and either you as the prescriber or a patient advocate may be most effective.

Some reasons why the claim may have been denied

Additional medical information may be required – Sometimes the claim may be denied because insufficient medical information was provided. It is important to make sure that all required information regarding a patient’s current medical condition, previous treatments, and medical history are provided. A claim may be reconsidered for reimbursement if the payer is sent additional information not previously available to them.

Off label prescribing – Some, but not all payers will consider reimbursement for drugs prescribed ‘off label’. This may require the prescriber to provide additional medical evidence including peer reviewed journal articles, scientific research, or clinical trial results to support your prescribing decision.

The drug prescribed is not in the insurer’s list of eligible drugs – If the drug you have prescribed is denied because it is not in the list of eligible drugs, not on the payer’s drug formulary for this group, then you may decide to prescribe an alternative drug and your patient can submit a new claim.