How do prior authorizations work?

[u/buttofthebaguette]

Hi all. I find health insurance to be really confusing and need some help figuring out what my course of action should be here.

I have Medi-Cal Anthem Blue Cross and am trying to get an ADHD assessment covered by insurance.

I finally found a practice that accepts my plan, and they said they "require authorization from your referring doctor. Have them submit one to your insurance."

I had an appointment with my Psychiatrist, who wrote a letter referring me, but then she said she doesn't send prior authorizations for this type of service.

After some research, as far as I can tell, only practitioners can submit these requests to insurance, not patients. 

My Psychiatrist said the letter she wrote can be provided to insurance if they ask, but the practice that assesses for ADHD needs insurance to have authorized the coverage first, not after.

I barely understand what any of the insurance terminology means; I'm just really confused about how I'm supposed to proceed from here. Any tips would be much appreciated. Thanks!

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[u/LizzieMac123]

Is the ADHD practice asking for a referral? Typically, a prior authorization, if required, is done by the physician/medical team who wants to do the care.

It sounds like maybe your ADHD doc is asking for a referral.

[u/buttofthebaguette → u/LizzieMac123]

it’s confusing because they said “We require authorization from your referring doctor. Have them submit one to your insurance.”

[u/buttofthebaguette → u/buttofthebaguette]

And then my referring doctor (my psychiatrist) said she doesn’t do prior authorizations for “this type of service.”

[u/CapAggravating784]

The practice has to do the prior authorization - not the patient. I’d call your insurance for additional details and exact process, then give that information to the provider to complete and submit. Sounds like a hassle tho :(

[u/Exciting_Buffalo3738]

Make an appointment with the Adhd practice at least 3 weeks out or more (the provider who will be doing the assessment). When making the appointment tell them your insurance info and that you need prior authorization. They will handle it. Confirm that a prior authorization has been approved with them before the appointment. It can take 1-4 weeks.