Prior authorization

Prior authorization (PA) is a rule a health plan applies before it agrees to pay. The prescriber submits a request, the plan reviews it against its own criteria, and coverage begins only once the plan approves.

A PA decision is a coverage decision, not a clinical one. A denial means the plan has not agreed to pay under its current rules — not that the treatment is wrong for the patient — and it can be appealed.

What patients ask your team

• What prior authorization is, and why their medicine needs one.
• Whether their request has been submitted, and where it stands.
• Why it was denied, and what happens next.

Why it matters to your program

PA is a common point for a newly prescribed therapy to stall, and status questions are inherently case questions: answering them takes access to the patient’s records, the plan and the prescriber’s office.

How OpenSupport handles it

Definitional questions get a short answer cited to its source. Status questions get a structured deferral: the assistant says it cannot see the patient’s records, invents no status or date, and names the channels that can help — the prescriber’s office, the specialty pharmacy, and the manufacturer’s support program.