Navigating the System

Empower yourself as a patient, and learn how to get the most out of your benefits. Each plan is different, so this section of our guide will help you understand what it is that you should look for when you receive your insurance information.  This section will help you navigate the health care system when you need care.

Topic Area: Getting care, what's covered

Do I need permission or authorization from my insurance company before I get medical care?

If you are having a health emergency, you do not need to get permission to access emergency care. Health plans do not require permission or authorization for a sick or wellness visit with a primary care provider.

Prior authorization from your insurance company is different from receiving a referral from a primary care doctor. Some services require prior authorization in addition to a referral. Prior authorization gives the clinical staff at an insurance company the chance to review treatment protocol, available health care providers, and contribute to the course of treatment.  Sometimes prior authorization serves to determine that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary, and other times it may begin the coordination between a nurse case manager and the health care providers you will receive treatment from. Prior authorization does not guarantee your insurance company will cover the entire cost of authorized services.

Examples of the more common health care services that may require prior authorization include:

  • Planned admission to a hospital or skilled nursing facilities
  • Surgeries
  • Advanced imaging, such as MRIs and CT scans
  • Transplant and donor services
  • Non-emergency air ambulance transport
  • Medical equipment
  • Specialty drug treatments

Review your Summary of Benefits and Coverage Document for more information about which services or supplies require prior authorization.

To get prior authorization

  • Health care providers usually initiate the prior authorization request from your insurance company for you. However, it is your responsibility to make sure that you have prior authorization before receiving certain health care procedures, services and prescriptions.
  • Call your insurance company before you receive your health care services or prescription.
  • Discuss the health care services or prescription that you need and ask if prior authorization is required.
  • If you need prior authorization, ask about the specifics. For example, ask how many prescriptions or visits will be approved. If you need to be hospitalized, ask how many days you will be allowed to stay.

If your insurance company doesn't grant prior authorization, you have 180 days from the date your claim was denied to file an appeal with your insurance company. Insurance companies are required to offer at least one level of appeal. The New Hampshire Insurance Department provides more detail about filing an appeal here.

To ensure timely access to necessary medications, New Hampshire requires that prior authorizations for prescription drugs take place within 48 hours. New Hampshire law allows a pharmacist to provide a patient with a 72-hour supply of a prescription drug and invoice the insurance company for the emergency need.


Was this answer helpful?