Mary’s* vacation to Mexico turned into an emergency when a bad fall knocked four of her front teeth loose and left her with a concussion. In the days that followed — during intense efforts to reset and save her teeth — Mary got news that a prior authorization request for treatment had not been approved.
Then, to her surprise, she got a call from a UnitedHealthcare registered nurse advocate who offered to help find a solution.
“We are an extra layer of support,” said Lisa Clark, a nurse and UnitedHealthcare advocate who specializes in helping members navigate prior authorization requests. “My job is to take another look and help the member understand the situation and possible options for moving forward.”\
A request to your health plan for pre-approval of a service or medication is called prior authorization. It is a measure put in place to help ensure health care is safe, necessary and cost-effective. It’s also been described as a checkpoint in the health system to verify that a service or prescription is a clinically appropriate treatment option.
In the past, the prior authorization process has happened mainly behind the scenes for most people — but that’s changing.
For eligible UnitedHealthcare members, a new health plan feature creates increased transparency for a prior authorization, including by enabling online tracking the request’s progress from start to finish. For people with access to enhanced advocacy support selected by their employer, a nurse advocate may be able to offer personalized help to find a solution when a prior authorization request has not been approved.
“We want to help the member understand why,” Lisa said. “In those cases, we answer their questions and work with them on other treatments that may be available with their coverage.”
Sometimes additional insight can help reverse the original decision — as was the case for Mary. Lisa investigated the original prior authorization request with Mary’s oral surgery team and discovered a coding issue.
“In the original request, dental codes were used to list the work,” Lisa said. “While dental services were being rendered, a medical emergency was the reason they were needed — and that put this work in the medical category.”
Lisa helped Mary resubmit the prior authorization request, which led to pre-approval of services and enabled Mary to continue her treatment.
“Mary told me, ‘I can’t believe that the insurance company is actually providing somebody to call and support me with all of this,’” Lisa said.
While not every case ends with such a change, Lisa says the guidance and support she and other nurses offer may help members feel more informed and more confident about their future care choices.
“I think this program is phenomenal,” Lisa said. “The end goal is support — and the ability to provide answers to a member’s questions and offer options that may be available.”
For additional information about nurse advocate support and the broader advocacy initiatives at UnitedHealthcare, visit uhc.com.
