Processing an Insurance Rejection or Prior Authorization — Practice Checklist

Step-by-Step Procedure (7 steps)

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 (4)

Confirm each of these before considering the task complete.

• 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.

Avoid These 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.