Processing an Insurance Rejection or Prior Authorization

Step-by-Step Procedure

1. 1

   Submit the claim and read the rejection code and message returned by the payer exactly as given (e.g., "Refill Too Soon," "Prior Authorization Required," "Non-Formulary," "Plan Limitations Exceeded").

2. 2

   Determine which category the rejection falls into: a technician-resolvable data issue (wrong day supply entered, wrong NDC, wrong patient plan on file) versus a clinical/coverage issue that requires prescriber or pharmacist involvement.

3. 3

   For technician-resolvable issues, correct the claim data and resubmit.

4. 4

   For "Refill Too Soon," check the actual days remaining and inform the patient of the earliest fill date, or escalate if there's a legitimate reason for early refill (lost medication, dose change, travel).

5. 5

   For prior authorization or non-formulary rejections, notify the pharmacist and, per pharmacy workflow, initiate the PA request to the prescriber's office (fax, portal, or phone, depending on the pharmacy system).

6. 6

   Document the rejection reason and the action taken in the patient's record/notes so the next person handling the claim has the full history.

7. 7

   Follow up with the patient about the delay and expected timeline, without promising a specific coverage outcome you can't guarantee.

Quality Checkpoints

• ✓

  The rejection code/message is read and categorized correctly before any action is taken — guessing at the fix wastes a submission attempt and delays the patient.

• ✓

  Technician does not attempt to resolve a clinical-coverage issue (e.g., override a true "too soon" rejection) without pharmacist sign-off.

• ✓

  Prior authorization requests are routed to the correct prescriber contact with the correct drug/strength/quantity information.

• ✓

  The patient is given an honest, non-committal timeline rather than a guaranteed approval.

Common Mistakes

• ⚠

  Resubmitting the exact same claim repeatedly without changing anything, hoping it clears — this wastes time and can trigger stricter payer scrutiny.

• ⚠

  Overriding a "refill too soon" rejection without actually checking the days remaining or getting pharmacist approval.

• ⚠

  Failing to document what was tried, leaving the next technician or pharmacist to start from scratch.

• ⚠

  Telling a patient their prior authorization "will definitely be approved" — technicians cannot make coverage guarantees.

On-the-Job Tips

• →

  Keep a running mental (or written) list of the payer-specific quirks you encounter most — some plans use nonstandard reject codes that are easy to misread the first few times.

• →

  When escalating a PA to a prescriber's office, include the exact drug, strength, quantity, and diagnosis code if available — incomplete PA requests bounce back and add days of delay.

• →

  A calm, specific update to the patient ("it's with your doctor's office for approval, typically 2-3 business days") reduces follow-up calls more than a vague "it's being worked on."

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