Did You Know: Prior Authorization

Did You Know:
Many health insurance carriers require prior authorization to repair CRT equipment that’s already been approved? 

Prior authorization is basically asking your health insurance carrier for permission before ordering the parts to complete a repair on CRT equipment that has previously been approved as medically necessary. The process involves submitting several documents and a variety of information to your insurance provider for approval. These often include: 

• A prescription,
• A repair evaluation; 
• An equipment or repair estimate, and 
• A Letter of Medical Necessity (LMN). 

Educate Yourself: Prior authorization requirements can differ depending on the health insurance carrier. Learn about your insurance carrier’s requirements and who is responsible for each step in the process so you know who to reach out to if documentation is missing or delayed. Also note, if you change health insurance carriers at any time during the repair process, you will have to start the process over with your new health insurance carrier as they likely have different prior authorization requirements.

How Would Changing the Prior Authorization Process Help CRT Users? 

Prior authorization creates bottlenecks in the process, delaying CRT users from getting the repair they need to achieve the level of independence and mobility they desire. Reforms to the prior authorization process and requirements would shorten the repair timeline and help CRT users keep moving, allowing them to enjoy daily activities and avoid additional health problems such as respiratory issues or pressure injuries that can develop from not having regular use of their customized mobility equipment.

A few ways prior authorization can slow down the process of making timely repairs include: 

• The authorization process is lengthy, often requiring several types of documentation to be completed by different members of the CRT user’s care team, including physicians, therapists and Assistive Technology Professionals (ATPs). Waiting for approvals from your health insurance carrier often makes up for nearly half of the repair timeline, adding one to four weeks to the process. 
• Authorization is required before ordering equipment or parts needed for a repair. It takes time to order, repair and deliver CRT equipment, and CRT providers cannot start the process until the health insurance carrier has approved. 
• If prior authorization is denied, you must appeal the decision, which often means submitting or resubmitting additional documentation and waiting for the health insurance carrier’s decision. 
• Even if your chair was previously approved and determined medically necessary, your health plan may require you to submit a prescription or Letter of Medical Necessity for most repairs—even replacing a battery. Learn more.

What Are Some Potential Solutions to Improve the Repair Timeline Process Related to Prior Authorization?

Reforms to prior authorization are needed to improve the CRT experience for users and their caregivers. These include: 

• Removing requirements for a prescription and a statement of medical necessity for repairs to equipment that has already been approved as medically necessary.
• Removing prior authorization or establishing a threshold up to $1,500 for minor repairs or frequently replaced parts to reduce unnecessary wait times and keep CRT users moving.  

Did You Know You Can Make a Difference? 

As a CRT user, your experience can help legislators and insurance carriers see the need for change. Legislation that seeks to remove or limit prior authorization is currently being considered in several states. You can help by: 

Research What’s Happening in Your State: Follow advocacy organizations like NCART, iNRRTS, AAHomecare and other advocates to stay up-to-date about ongoing efforts and learn what is happening in your state. If legislation is under consideration in your state, research and seek to understand how it would change the prior authorization process for you and your health insurance carrier. 

Share Your Story: Reach out to your insurance carrier and elected officials at both the state and federal level and explain how changes to prior authorization requirements would improve your daily life. Find your elected officials. 

Make Your Voice Heard: In many ways, private health insurance plans follow the example of Medicare and Medicaid. Call the Centers for Medicare and Medicaid Services (CMS) directly at 1-800-633-4227 to changes to prior authorization requirements.