1. Non-Formulary Drugs & Prior Authorization Denials
Cause: The medication is not included on the patient’s insurance formulary or is explicitly excluded from coverage.
Prevention:
- Include all of the previous medications including outcomes and durations.
- If clinically necessary, include strong documentation and rationale for using a non-formulary drug when submitting the PA.
2. Missing Clinical Justification in PA Requests
Cause: The PA lacks necessary documentation such as past treatment history, diagnosis codes, or lab results demonstrating necessity.
Prevention:
- Use structured PA templates that prompt providers to include:
- Step therapy failures
- Diagnosis with ICD-10 code
- Supporting clinical notes and labs
According to the American Medical Association, most physicians say PA causes care delays
3. Step Therapy Gaps Causing PA Denials
Cause: Insurers require the patient to try and fail lower-cost or first-line medications before approving the requested one.
Prevention:
- Clearly document previous therapies tried, including duration, dosage, and patient response.
- Submit evidence of contraindications or adverse reactions if bypassing step therapy is necessary.
4. Quantity Limits and Dosage Rejection
Cause: The requested dosage or quantity exceeds what is permitted by the payer without additional approval.
Prevention:
- If higher quantities or doses are clinically justified, include medical rationale and titration plan in the PA.
5. Manual Submissions and PA Delays
Cause: Manual fax submissions, errors in routing to the correct PBM, or delays in initiating PA can lead to denials or processing timeouts.
Prevention:
- Use real-time ePA (electronic prior authorization) systems like Karova Health.
- Set up alerts for medications that typically require PA.
Learn how Karova Health uses AI to automate prior authorization submissions.
Tired of denials delaying care?
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