Some insurance plans need to approve certain care before they will pay for it. This approval is called a prior authorization. A prior authorization can apply to prescriptions, specialist appointments, imaging, some lab tests, and medical equipment. Each one works a little differently.
This article explains what a prior authorization is, how long it usually takes, what you may need to send us, when to reach out, and what to do if your insurance denies it.
Looking for something else? If your HMO needs a referral to Circle Medical so we can bill your visits, that is a different process. See How to get your HMO referral.
What is a prior authorization?
A prior authorization (also called a pre-authorization or PA) is approval from your insurance plan before it will cover a specific prescription, procedure or test, appointment, or item.
Your insurance decides. Circle Medical, your pharmacy, or another facility can send the request, but only your insurance plan can approve or deny it.
It can be required even for covered care. If a prior authorization is required and not approved, you may be responsible for the full cost.
It expires, separately from your order. An approval lasts for a set time, and that is usually shorter than how long your referral, order, or prescription is valid. Your insurance plan may also ask for a new one when your benefits change or at the start of a new plan year. See How long an approval lasts below.
It does not apply if you pay yourself. If choose to self-pay, you do not need a prior authorization.
Tip: To check whether something needs a prior authorization, call the member services number on the back of your insurance card, or review your insurance benefits booklet.
What can need a prior authorization?
A prior authorization is not one process. Who requests it, how long it takes, and what happens next depend on what it is for. Find your type of care below, then see the linked article for the full steps.
Prescriptions. Most common for brand-name drugs when a generic exists, higher-cost medications, and some weight loss medications. Your pharmacy usually tells us when one is needed. This article covers prescriptions in the most detail. See also Requesting medication refills.
Specialist visits. Some plans, particularly HMOs, require one before covering a visit to a specialist. We request it when we send your referral. See How specialist referrals work at Circle Medical.
Imaging. CT scans, MRIs, MRAs, and mammograms most often need one. The imaging facility usually requests it. See How imaging orders work at Circle Medical.
Lab tests. Usually not needed. Specialized or expensive tests, like genetic testing, may need one. See How lab orders and testing work.
Medical equipment. Continuous glucose monitors often need one. A CPAP sometimes does. See How medical equipment prescriptions work.
Some services and programs. Some plans require one for weight loss programs, sleep studies, or behavioral health care such as ADHD evaluations.
Note: Circle Medical cannot do a prior authorization for its own services. If you have an HMO plan and are being referred to Circle Medical, your insurance-assigned PCP will have to submit a prior authorization before you can be seen by Circle Medical. See How to get your HMO referral.
How long does a prior authorization take?
Each type has its own clock, and your insurance sets it. Some decisions come back right away. Others take longer.
Prescriptions: usually 3 to 5 business days after the request is sent, sometimes longer.
Specialist visits: immediate up to 14 days.
Imaging: immediate up to 14 days.
Medical equipment: varies by plan and item. Some decisions come back right away.
Lab tests: varies by plan and test.
Important note: If your insurance asks to speak with your provider directly, called a peer-to-peer review, it can add a few days. We arrange this with your provider, and you do not need to do anything.
How long an insurance approval lasts
Once your insurance approves a prior authorization, the approval is active for a set time, counted from the date the prior authorization was requested. Typical timeframes:
Prescriptions: 12 months
Specialist visits: 6 months
Imaging: 3 months
Medical equipment: 3 months
Your plan sets the exact timeframe, and it can be shorter. Check your approval letter or your insurance portal for the end date.
Your approval and your order expire at different times. These timeframes are separate from how long your referral, order, or prescription is valid. For example, an imaging order is valid for 6 months, but an imaging approval usually lasts 3 months. If you book your scan after the approval ends, your plan may need a new prior authorization before it will pay, even though your order is still valid. Book your care soon after you're approved.
How the process works
Step 1: Someone finds out a prior authorization is needed
This depends on the type of care:
Prescriptions: your pharmacy tries to fill the prescription, and your insurance tells them a prior authorization is needed. The pharmacy then notifies us.
Specialist visits: the support team checks when sending your referral.
Imaging and medical equipment: the facility or supplier usually finds out when they receive your order.
Step 2: The request is sent to your insurance
The request explains why your provider ordered the care, using your appointment notes and medical history.
Prescriptions: Circle Medical submits the request.
Specialist visits: Circle Medical submits the request as part of sending your referral.
Imaging: the imaging facility usually submits the request, because it has to match the exact procedure they perform.
Medical equipment: it depends on the item. We often submit it for a glucose monitor. The equipment company may submit it for a CPAP.
If a pharmacy, facility, or supplier tells you that Circle Medical needs to submit the request, start a chat. Include their name and what they asked for.
Step 3: Your insurance reviews the request
Your insurance compares the request with your plan's rules and benefits. A provider's recommendation does not guarantee approval. Your plan decides based on its own criteria. Your insurance may also ask for more information or a peer-to-peer review.
Step 4: You get a decision
Your insurance shares its decision with Circle Medical and with your pharmacy, facility, or supplier. Insurance will contact you directly re: your prior authorization status, or will have the prior authorization decision available on your insurance portal.
If approved: your pharmacy can fill the prescription, or the facility, specialist, or supplier can schedule or provide your care. For a prescription, you may need to contact your pharmacy to refresh the prior authorization status before filling.
If denied: see My prior authorization was denied below.
What you may need to send us
For prescriptions
To submit a prior authorization for a medication, we need these details from your prescription or pharmacy benefits card (often your medical insurance card, but can be separate):
Member ID
RxBIN
PCN
RxGroup
If you have your card: take clear photos of the front and back, then start a chat and send them there.
If you do not have your card, or details are missing: call your insurance and ask for your Member ID, RxBIN, PCN, and RxGroup, then send them in chat.
For specialist visits, imaging, lab tests, and medical equipment
You usually do not need to send anything extra. We use the insurance details saved on your account, so keep them up to date. An out-of-date insurance card is a common reason a request has to be redone.
Tip: If the support team is helping with your prior authorization, watch for updates in your chat.
Can a prior authorization be expedited?
Insurance plans usually only expedite a prior authorization if waiting for the standard review could put your life or health at serious risk.
When to contact the support team
Most prior authorizations move without you needing to do anything. Use these checkpoints so you're not waiting on an update that is already on its way:
Prescription, no update 5 business days after your pharmacy said a prior authorization was needed: call your insurance to check the status. If your insurance has no record of a request, start a chat.
Specialist visit, no referral sent message after 4 business days from your appointment: start a chat. A prior authorization may still be pending.
Imaging, no update after 2 weeks: call your insurance to check the status, and start a chat so we can follow up with the facility.
A pharmacy, facility, or supplier says Circle Medical needs to submit it: start a chat with their name and what they asked for.
Your insurance changed while a request is in progress: update your insurance details on your account, then start a chat. A new request may be needed.
Your request was denied: see below.
What to do if something goes wrong
I haven't heard anything about my prior authorization
Your request may still be under review. Common reasons for a delay:
Your insurance asked for more information or a peer-to-peer review.
The insurance details on your account are out of date or missing pharmacy card details.
The pharmacy, facility, or supplier has not yet told us a request is needed.
Check the timeline for your type of care above. If it has passed, follow the checkpoints in When to contact the support team.
My prior authorization was denied
A denial does not always mean you can't get the care. Your insurance makes the final coverage decision, including a decision that something is "not medically necessary". Circle Medical does not make that decision, but we can help you with next steps.
Your options can include:
Talk to your provider about alternatives. There may be a covered medication, a different test, or another approach. Book a follow-up appointment or start a chat.
Appeal the decision. You have the right to appeal. Follow the instructions in your denial letter. An appeal usually only succeeds if we can send new information that meets your plan's criteria, or make a strong case for why your care should qualify. An appeal determination by your insurance often takes closer to a month. Get in touch with us if you want to appeal the decision - we can help advise on next steps or may be able to provide more evidence.
Pay for it yourself. Ask the pharmacy, facility, or supplier for the self-pay price before you decide.
If a prescription prior authorization was denied
Medication denials have a few extra options and limits:
Ask your insurance which medications are covered. Ask for the covered list (sometimes called a formulary), then review the options with your provider.
Formulary exception. If your plan normally excludes the medication, your provider may be able to request an exception.
Formulary exclusion. Some insurance plans will not cover certain medications, particularly certain GLP-1s, and these decisions cannot be appealed. Ask your provider for alternatives.
Try a lower-cost option first. Some plans require you to try a lower-cost medication before they will cover the one originally prescribed. Generics are often covered instead of brand name medications.
Quantity limits. Some plans only cover a certain amount of a medication, or only cover it when specific conditions are met.
Discount programs. If you pay yourself, prescription discount programs and coupons may lower the cost.
If a specialist visit, imaging, or equipment prior authorization was denied
Your provider is told about the decision and can discuss alternatives with you. See the article for your type of care:
My prior authorization expired, or my plan wants a new one
An approval only lasts for a set time (see How long an approval lasts above), and it can run out before your referral, order, or prescription does. Your plan may also need a new prior authorization when your benefits change, or at the start of a new plan year. If your pharmacy, facility, specialist, or supplier tells you a new one is needed, start a chat so we can help submit it.
I changed insurance
A prior authorization approved by one plan does not carry over to a new plan. Update your insurance details on your account and start a chat. Your new plan may need its own request.
Related articles
Specialist referrals: How specialist referrals work at Circle Medical
Lab orders: How lab orders and testing work
Medical equipment: How medical equipment prescriptions work
Still have a question about a prior authorization? Start a chat in the app or web portal to connect with the support team. Please include what the prior authorization is for, and the pharmacy, facility, or supplier name, so we can help faster.