Does Secondary Insurance Require Prior Authorization?

Navigating the complexities of health insurance can be challenging, particularly when multiple plans are involved. A common question arises regarding prior authorization requirements, especially for individuals with more than one insurance policy. This article explores whether secondary insurance plans typically require prior authorization and outlines important considerations for policyholders.

Prior Authorization in the Context of Secondary Coverage

Prior authorization (PA) is a process where an insurer reviews a proposed medical service, medication, or procedure to determine if it meets coverage criteria before it is performed. This step helps insurance companies manage costs and confirm the medical necessity of a treatment. Without prior authorization, the health plan may not cover the service, leaving the patient responsible for the full cost.

Secondary insurance provides additional coverage beyond what a primary insurance plan offers, helping to cover out-of-pocket expenses such as deductibles, copayments, and coinsurance. The interaction between primary and secondary plans is governed by Coordination of Benefits (COB) rules, which determine which plan pays first (primary) and which pays second (secondary), preventing duplicate payments for the same service.

While the primary insurer often handles the initial prior authorization, a secondary insurance plan may have its own independent prior authorization requirements based on its specific terms and guidelines. This means even if the primary insurer approved a service, the secondary insurer might still require its own separate approval before covering its portion of the cost.

Services Commonly Requiring Secondary Prior Authorization

Secondary insurance plans often require prior authorization for specific types of medical services or situations, typically those that are high-cost, involve specialized care, or have alternative treatment options. These requirements help insurers control expenditures and ensure treatments align with established medical guidelines.

Common services requiring secondary PA include:
Elective surgeries, such as cosmetic procedures or certain orthopedic interventions.
Specialized diagnostic tests, including MRIs, CT scans, and PET scans.
Certain prescription medications, particularly high-cost or specialty drugs.
Durable medical equipment (DME), such as wheelchairs or oxygen equipment.
Mental health services, including therapy sessions or psychiatric evaluations.
Physical therapy, occupational therapy, and out-of-network care.

Identifying Prior Authorization Requirements for Your Secondary Plan

To determine prior authorization requirements for your secondary insurance plan, review your policy documents, such as the member handbook or summary of benefits. These materials typically outline services that require prior approval.

Another valuable resource is the insurer’s official website or member portal. These platforms often provide detailed lists of services subject to prior authorization. Many insurers also have a search tool where you can check if a particular procedure or medication requires pre-approval.

The most direct approach is to contact your secondary insurance provider directly. You can reach their member services line, typically found on your insurance card or the company’s website. When speaking with a representative, ask specific questions about the service you anticipate receiving. Inquire whether a particular service code or diagnosis code requires prior authorization for your plan.

It is beneficial to ask for confirmation in writing or to note the date, time, and name of the representative you spoke with, along with a reference number for the call. Obtaining this information before receiving services is important, as failure to secure prior authorization can result in claim denials, leaving you responsible for the full cost.

Steps for Obtaining Prior Authorization with Secondary Insurance

If prior authorization is required by your secondary insurer, your healthcare provider typically submits the request. Healthcare providers are generally responsible for submitting the request, as they have the necessary clinical information and medical documentation.

The information typically required for submission includes comprehensive medical records, specific diagnosis codes, and procedure codes relevant to the treatment. Details about any prior treatments or therapies, their clinical response, and the reason for the current proposed treatment are often needed. An Explanation of Benefits (EOB) from the primary plan may also be required by the secondary insurer to understand the remaining balance.

Requests can be submitted through various methods, including online portals, fax, or phone calls. After submission, track the status of the request through the insurer’s member portal or by contacting their dedicated prior authorization department. The decision-making process can range from a few days to several weeks.

If the prior authorization request is approved, the approval is typically valid for a defined timeframe. If the request is denied, both the patient and provider will be notified, often with a reason for the denial. In such cases, an appeals process is typically available, which may involve submitting additional documentation, a letter of medical necessity, or initiating a peer-to-peer review with the insurer’s medical reviewer.