What Is Prior Authorization? The 2026 Connecticut Patient Guide to PA, Step Therapy, Denials, and Appeals

Why Prior Authorization Is the #1 Patient Frustration in 2026

Ask any Connecticut primary-care office in 2026 what consumes more of their staff’s time than anything else and the answer is identical: prior authorization. The American Medical Association’s 2025 survey found that the average physician practice now completes 43 prior authorizations per week per physician — over 2,000 PAs per year — and that 94% of physicians report PA-related care delays for their patients. For patients, the experience is a black-box one: the doctor orders the MRI, prescribes the medication, schedules the surgery, and a week later a message appears in MyChart saying ‘pending insurance authorization’ with no estimated resolution date.

Prior authorization didn’t always look like this. In the 1990s, PA was reserved for genuinely high-cost or experimental services. By 2020, insurers had expanded PA to cover everything from generic medications to routine knee MRIs to physical therapy visits. In 2024, the U.S. Department of Health and Human Services Office of Inspector General reported that Medicare Advantage plans denied 13% of PA requests that would have been covered under traditional Medicare — finding that millions of medically necessary services were being inappropriately blocked. CMS responded with sweeping reforms that take full effect January 1, 2026.

This article exists to demystify prior authorization for Connecticut patients. We walk through the entire 2026 PA landscape: what triggers it, how long insurers have to decide, what your rights are under both new federal CMS rules and Connecticut state law, how step therapy works, what to do when you’re denied, how a peer-to-peer review actually goes, how to file an internal appeal, and finally how to escalate to the Connecticut Insurance Department’s external review process — which overturns insurer denials about 50% of the time. Throughout, we include exactly what a licensed Connecticut broker — Antonucci, Joseph (CT #21658409) at We Find Your Insurance — does for clients trapped in PA limbo.

What Prior Authorization Actually Is

Prior authorization (also called ‘precertification,’ ‘pre-authorization,’ ‘PA,’ or ‘pre-approval’) is the requirement from a health insurer that your provider obtain written approval BEFORE delivering certain services, dispensing certain drugs, or scheduling certain procedures. Without that pre-approval, the insurer will deny the claim entirely — leaving you on the hook for the full billed charge, which on a high-cost imaging study or specialty drug can mean thousands of dollars out of pocket.

Critically, prior authorization is NOT the same as referral or coverage determination. A referral is your PCP’s written permission to see a specialist (required in HMO and POS plans). A coverage determination is the insurer’s general statement that a service falls within your plan’s benefits. Prior authorization is an additional, service-specific approval where the insurer reviews medical records and decides whether THIS particular service for THIS particular patient is medically necessary RIGHT NOW. You can have a fully covered benefit, a valid referral, an in-network provider — and still get denied because PA wasn’t granted.

PA can be triggered by drug (most specialty and many brand-name drugs require PA per the plan’s formulary), by procedure (most advanced imaging, sleep studies, inpatient admissions, joint replacements, gastric bypass, infusions, durable medical equipment over a certain price threshold), by place of service (a procedure done in a hospital outpatient department may need PA when the same procedure at an ambulatory surgery center does not), or by frequency (your plan covers 30 physical therapy visits but requires PA after the 12th). Every plan publishes its own PA list, and it changes every January 1.

The legal framework: ERISA, Medicare, and state insurance regulations all permit prior authorization as a ‘utilization management’ tool. The ACA prohibits PA from being used as a backdoor denial of essential health benefits, and Connecticut Public Act 22-58 prohibits PA from delaying urgent or emergent care. But within those guardrails, insurers have wide discretion.

Why Insurers Use PA (and What They Won’t Admit)

Insurers will tell you prior authorization exists to ensure ‘medically appropriate, evidence-based care.’ That’s partially true. PA does sometimes catch genuinely inappropriate prescribing — a doctor ordering a brand-name drug when generic works, or scheduling a CT scan when ultrasound is the indicated first-line test. In those cases, the PA process functions as a quality-control checkpoint.

What insurers won’t admit is that PA is also a cost-control mechanism that works in two ways. First, by adding friction to expensive services, some patients give up and don’t pursue care — saving the insurer the cost. The AMA estimates 30% of patients abandon prescribed treatment after a PA denial. Second, even when PA is eventually approved, the delay shifts costs: a patient whose MRI is delayed by 14 days while PA is processed may end up out of the deductible year for that scan, which means the insurer pays less for it the following plan year. Both effects directly improve the insurer’s medical loss ratio.

The 2024 OIG report on Medicare Advantage PA found that the highest denial rates were on services where MA plan PA criteria were stricter than Original Medicare’s published coverage rules. In other words: MA plans were using PA to deny services that Original Medicare would have paid for without question. CMS’s new 2026 rules directly target this practice by requiring MA plans to align PA criteria with Original Medicare coverage.

What Services Typically Require Prior Authorization in 2026

Every plan publishes its own PA list, but the categories are remarkably consistent across CT carriers:

Common PA-Required Services (2026 CT Commercial & Medicare Advantage)

Services that typically do NOT require PA: ER visits (federal law prohibits PA for emergencies), most primary-care visits, most generic drugs (Tier 1 and Tier 2), preventive care covered at 100% under ACA (annual physicals, mammograms, colonoscopies, vaccines), most lab work, basic X-rays, and post-stabilization care after an emergency.

Sources: CT Insurance Department Consumer Guide

The PA Process Step-by-Step

Here is exactly what happens, in order, when a PA-requiring service is ordered:

• Step 1 — Order placed: Your provider orders the medication, imaging, procedure, or admission inside their electronic health record (EHR). The EHR flags PA-required services automatically based on your insurance card information.
• Step 2 — PA request submitted: A clinical staff member (nurse, medical assistant, or pharmacy tech) submits the PA to your insurer. This is done via the insurer’s online portal (Anthem Availity, ConnectiCare provider portal, Aetna NaviNet) or via fax for legacy carriers. The submission includes diagnosis codes (ICD-10), procedure codes (CPT or HCPCS), clinical justification, and supporting documents.
• Step 3 — Insurer review: The insurer’s utilization management team — usually a registered nurse, sometimes a pharmacist for Rx PAs — reviews the request against the plan’s medical-necessity criteria. The reviewer may approve, deny, or request additional information.
• Step 4 — Decision communicated: The insurer notifies your provider (and increasingly the patient directly) of the decision. Approval comes with an authorization number that must accompany the claim. Denial includes a stated reason and your appeal rights.
• Step 5 — Service delivered: If approved, the service proceeds. If denied, the patient and provider must decide whether to appeal, modify the order, or accept the denial.
• Step 6 — Claim filed: After the service, the provider files the claim referencing the authorization number. The insurer pays per plan benefits.
• Step 7 — Appeal (if needed): The patient or provider files a written appeal within the timeframe specified in the denial letter (usually 180 days for commercial, 60 days for Medicare). If the internal appeal is denied, the patient can escalate to CID external review.

Critical reality: every step adds time. Provider PA submission typically happens within 1–3 business days of the order. Insurer review takes anywhere from minutes (auto-approved electronic requests for low-risk drugs) to 14+ calendar days (manual reviews for high-cost specialty drugs). Internal appeals take another 30–60 days. External review at CID takes 30–45 days. Total time from initial order to resolved denial-and-overturn can easily exceed 90 days.

New 2026 CMS Prior Authorization Rules

CMS’s Interoperability and Prior Authorization Final Rule (CMS-0057-F), published in January 2024, takes full effect January 1, 2026 for Medicare Advantage, Medicaid Managed Care, CHIP Managed Care, and Qualified Health Plans sold on federal exchanges. The rule does NOT apply to commercial group plans or self-funded ERISA plans, but most major commercial carriers are voluntarily adopting equivalent standards.

What changes in 2026:

• Decision timelines tighten: 7 calendar days for standard PA, 72 hours for urgent PA. Previously many plans took 14–30 days.
• Public reporting: Insurers must publish annually their PA approval rates, denial rates, and average decision turnaround time. This is a transparency revolution.
• Specific denial reasons: Insurers must include in every denial the specific clinical criterion not met, not boilerplate language like ‘not medically necessary.’
• Electronic submission required: Insurers must accept PA requests through a standardized FHIR API (Fast Healthcare Interoperability Resources), eliminating the fax workflow that dominated for decades.
• Provider real-time access: Providers can query a patient’s PA requirements at the point of order, knowing instantly what services need PA on the patient’s specific plan.
• Patient access: Patients can request and receive their full PA history (approved and denied) through their plan’s patient portal.

The new rules also require Medicare Advantage plans to align PA criteria with Original Medicare coverage. If Original Medicare would pay for a service without PA, MA plans cannot impose stricter PA than the Local Coverage Determination (LCD) or National Coverage Determination (NCD) for that service. This is enforced through the new annual PA reporting requirement.

Sources: CMS-0057-F Final Rule

Connecticut Prior Authorization Laws (PA 22-58, PA 23-171)

Connecticut has been a national leader on prior-authorization reform. Two statutes establish patient rights beyond federal minimums:

Public Act 22-58 (effective January 1, 2024) requires Connecticut-regulated commercial insurers to: (1) maintain a clear, public list of all services and drugs requiring PA, (2) respond to standard PA requests within 5 business days, (3) respond to urgent PA requests within 24 hours, (4) prohibit PA for generic drugs in maintenance therapy when the patient has been stable for 6+ months, (5) honor a PA approval for the entire course of treatment (no mid-treatment re-authorization for chronic conditions), and (6) accept PA submissions electronically.

Public Act 23-171 (effective October 1, 2024) added step-therapy reform: insurers must grant exceptions when (a) the patient has already tried and failed the preferred drug, (b) the preferred drug is contraindicated or likely to cause adverse reactions, (c) the patient is stable on a non-preferred drug already, or (d) delay would cause irreversible harm. Insurers must decide step-therapy exception requests within 72 hours for standard or 24 hours for urgent. These exceptions must be communicated in plain language with appeal rights.

Importantly, these CT laws apply only to fully insured plans regulated by the Connecticut Insurance Department. They do NOT apply to self-funded ERISA employer plans, Medicare (which is federally regulated), or Medicaid Managed Care (which has its own state-administered rules, generally aligned with the federal CMS reforms). Roughly 55% of CT employer plans are self-funded, so they fall outside PA 22-58 and PA 23-171.

Sources: Connecticut PA 22-58 Full Text

Step Therapy (‘Fail First’) Rules

Step therapy is a specific type of utilization management: insurer requires patients to try one or more lower-cost drugs (Step 1) before they’ll pay for the more expensive prescribed drug (Step 2 or Step 3). The rationale: if the cheaper drug works, why pay for the expensive one? The practical reality: step therapy delays effective treatment by weeks or months while patients try drugs that may not work for their specific condition.

Common 2026 CT step-therapy protocols:

Common Step Therapy Pathways (CT 2026)

Connecticut Public Act 23-171 grants four explicit step-therapy exceptions, and Connecticut providers should request them aggressively when justified. The exception request takes the form of a letter (often template-driven inside the EHR) citing the specific exception ground, attaching documentation, and requesting decision within 72 hours. Insurers that fail to respond within 72 hours under PA 23-171 are deemed to have granted the exception.

How Each Connecticut Carrier Handles PA in 2026

PA experience varies significantly by carrier. Based on Connecticut Insurance Department complaint data and 2025 provider surveys:

Anthem CT (Elevance Health): Uses Availity portal with FHIR API integration since mid-2025. Approval rate for standard drug PAs runs around 78%. Imaging PA handled by Carelon Medical Benefits Management (formerly AIM). Average turnaround: 3–5 business days for standard, 24 hours for urgent. CID complaint rate: moderate. Step-therapy exceptions granted readily when properly documented.

ConnectiCare (Emblem subsidiary): Uses provider portal with growing electronic PA. Approval rate around 81%. Imaging PA handled internally. Average turnaround: 2–4 business days for standard, same day for urgent. CID complaint rate: low. Notably patient-friendly on PA for established CT residents on long-term therapy.

CTCare Benefits: Smaller plan with manual review processes. Approval rate around 75%. Average turnaround: 5–7 business days, sometimes longer for specialty drugs. CID complaint rate: low (smaller volume). Less responsive to peer-to-peer review requests than larger carriers.

Aetna (CVS Health) — CT Medicare Advantage and commercial group: Uses NaviNet portal. Approval rate around 73% for MA, 79% for commercial. Heavy use of step therapy. Average turnaround: 4–7 business days. Specialty drug PAs routed through CVS Specialty Pharmacy. CID complaint rate: moderate-high in 2025.

UnitedHealthcare CT MA: Uses UHC Provider Portal. Approval rate around 71% — among the lowest in CT. Aggressive PA for imaging through Optum. Average turnaround: 5–10 business days. CID complaint rate: high. Frequent target of provider frustration. The OIG specifically called out UHC in its 2024 report for denying MA PAs that Original Medicare would have approved.

Humana CT MA: Uses Availity. Approval rate around 79%. Generally responsive on appeals. CID complaint rate: low-moderate. Strong peer-to-peer process; physicians report Humana’s medical directors are typically responsive within 48 hours.

Prior Authorization Inside Medicare Advantage Plans

Original Medicare (Parts A and B) uses prior authorization for only a narrow set of services — primarily certain DME (power wheelchairs, advanced prosthetics), some non-emergent hospital outpatient department procedures, and home health services in specific markets. Outside those categories, Original Medicare pays clean claims without PA.

Medicare Advantage plans, by contrast, apply PA to a vast range of services. The 2024 OIG report studied a sample of MA PA denials and found that 13% were for services Original Medicare would have covered without question — meaning MA plans were using PA to deny medically necessary care. The 2026 CMS rule directly responds: MA plans must align PA criteria with Original Medicare coverage policies, must decide standard PA within 7 days, and must publish PA approval/denial rates by service category.

Practical impact: If you’re on a CT Medicare Advantage plan in 2026 and your PA is denied for a service that Original Medicare would cover, your appeal should specifically reference CMS-0057-F and the Original Medicare LCD/NCD. Properly framed appeals using this rationale are overturned at very high rates.

Many CT seniors with serious chronic conditions choose Original Medicare + Medigap precisely to avoid MA prior authorization friction. The trade-off: Medigap premiums of $200–$400/month versus MA $0 premiums. For a senior on a biologic, a heart procedure on the horizon, or any high-acuity care plan, the Medigap premium is often the better value because PA delays don’t apply.

Drugs That Almost Always Require PA in 2026

The 2026 drugs most commonly subject to PA across CT carriers:

• GLP-1s for weight loss: Wegovy, Zepbound, Saxenda — almost universal PA with BMI documentation, weight-loss attempts, comorbidity proof
• GLP-1s for diabetes: Ozempic, Mounjaro, Trulicity, Rybelsus — PA usually requires A1C >7.0 and failed metformin
• Biologics for autoimmune: Humira biosimilars (Yusimry, Hadlima, Amjevita), Enbrel, Stelara, Skyrizi, Cosentyx, Taltz, Cimzia, Rinvoq, Xeljanz — PA with diagnosis confirmation, lab values, prior therapy failure
• Migraine CGRPs: Aimovig, Emgality, Ajovy, Vyepti, Nurtec, Ubrelvy, Qulipta — PA with monthly migraine days documented, failed first-line preventives
• Multiple sclerosis: Ocrevus, Kesimpta, Tysabri, Mavenclad, Tecfidera — PA with neurologist documentation, MRI findings
• Hepatitis C: Mavyret, Epclusa, Vosevi — PA with viral load, fibrosis stage
• PCSK9 inhibitors: Repatha, Praluent — PA with LDL >100 on max statin, documented statin intolerance, or familial hypercholesterolemia
• Inflammatory bowel: Stelara, Skyrizi, Remicade biosimilars, Entyvio — PA with colonoscopy, failed first-line
• Oral oncology: Ibrance, Verzenio, Kisqali, Tagrisso, Imbruvica — PA with biomarker testing, oncology rationale
• Specialty allergy: Xolair, Dupixent, Nucala, Fasenra, Tezspire — PA with diagnosis, prior therapy failure
• ADHD: Vyvanse (now generic), Adderall XR, Concerta — PA limited but quantity limits and step therapy common
• Sleep apnea: CPAP/BiPAP machines — PA with sleep study results and AHI threshold met

Procedures That Almost Always Require PA

• MRI of any body part — almost universal in 2026
• CT scans (except trauma in ER) — almost universal
• PET scans — always
• Cardiac catheterization (elective) — always
• Knee replacement — always with documentation of failed conservative care, BMI documentation, imaging
• Hip replacement — same as knee
• Spine surgery (laminectomy, fusion) — always with failed conservative care, imaging, neurological findings
• Bariatric surgery — always with documented BMI threshold, comorbidities, pre-surgical evaluations, behavioral health clearance, often 6-month medically supervised diet
• Sleep studies — usually
• Genetic testing (BRCA, expanded carrier, oncotype, whole-exome) — almost always
• Inpatient psychiatric admission — always (with retro option in true emergencies)
• Residential substance use treatment — always with ASAM criteria documentation
• Out-of-state non-emergency care — always when PPO/POS allows it
• Skilled nursing facility admission (Medicare Advantage) — always
• Home health beyond initial certification period — always
• Infusion services (Remicade, Ocrevus, IVIG, monoclonal antibody) — always

What Happens When PA Is Denied

A PA denial is not a final answer — it’s the start of a multi-step appeal process. Every denial letter must include: (1) the specific clinical or coverage reason for the denial, (2) the medical-necessity criteria the request did not meet, (3) the name and credentials of the reviewer who made the decision, (4) your right to appeal and the deadline, and (5) your right to request a peer-to-peer review with the insurer’s medical director.

Common stated denial reasons in 2026 and what they actually mean:

Common PA Denial Reasons Decoded

Statistical reality: across the U.S. in 2024, only 11% of commercial PA denials were appealed by patients — but among those that were appealed, 80% were overturned in favor of the patient (KFF analysis). The system disproportionately benefits patients who fight back. The vast majority of denials stick simply because nobody challenges them.

Peer-to-Peer Reviews — How Doctors Win Approvals

When a PA is denied, your treating physician has the right to request a ‘peer-to-peer’ (P2P) review — a phone call with the insurer’s medical director (or pharmacist for drug PAs) to discuss the case directly. P2P is often the fastest path to overturning a denial. Properly conducted P2Ps overturn denials roughly 60–70% of the time, often within 24 hours.

Mechanics: the prescribing provider’s office calls the insurer’s P2P scheduling line within the timeframe specified in the denial letter (usually 1–7 business days). The call is scheduled — typically within 24–72 hours. The treating physician personally presents the clinical justification to the insurer’s medical director. If the medical director agrees the criteria are met, the denial is overturned same-day with verbal authorization, followed by written confirmation.

What makes a P2P successful: the treating physician is on the call (not a nurse, not a PA), specific clinical evidence is cited (recent labs, imaging, prior therapy outcomes), and clinical guidelines are referenced (NCCN for oncology, ACC/AHA for cardiology, ADA for diabetes). Pre-canned templates and EHR auto-text dramatically underperform personalized clinical narratives.

The Internal Appeal Process

If P2P fails or isn’t pursued, the next step is a formal internal appeal. Filed in writing (usually via fax, secure portal, or certified mail) within the deadline stated in the denial letter — 180 days for ACA commercial plans, 60 days for Medicare Advantage, 30–60 days for most employer plans.

A strong internal appeal contains: a clear cover letter citing the denial date and reference number, a physician letter of medical necessity (LOMN) detailing diagnosis, prior treatments, specific reason the requested service is needed, and citation of clinical guidelines, supporting medical records (labs, imaging, consult notes, prior therapy documentation), peer-reviewed literature supporting the treatment, and the patient’s personal impact statement when relevant (especially for QOL, functional, or mental health justifications).

Insurers must decide standard internal appeals within 30 days for pre-service requests and 60 days for post-service. Urgent appeals must be decided within 72 hours. If the insurer fails to respond within these timeframes, the appeal is deemed exhausted and the patient may proceed directly to external review.

Connecticut External Review With the CID

Once internal appeals are exhausted (or deemed exhausted), Connecticut patients have the right to request an Independent External Review through the Connecticut Insurance Department. The review is conducted by an Independent Review Organization (IRO) — a third-party medical expert with no financial relationship to the insurer. The IRO’s decision is binding on the insurer.

Process: file the CID External Review Request Form (available at portal.ct.gov/cid) within 4 months of the final internal denial. The CID forwards the case to a contracted IRO within 5 business days. The IRO reviews medical records, applicable clinical guidelines, and any patient/provider submissions. Standard review: decision within 45 days. Expedited urgent review: decision within 72 hours.

CT external review success rate: based on CID 2024 annual report, approximately 50% of external reviews overturned the insurer denial. For specialty drug denials specifically, the overturn rate was 58%. There is no cost to the patient for external review. This is the single most powerful tool Connecticut patients have to fight unreasonable PA denials.

Sources: CID External Review

External review covers: medical necessity disputes, experimental/investigational disputes, and rescission of coverage. It does NOT cover: pure contract benefit interpretations (where the service is genuinely excluded by the plan), eligibility disputes, or copay/deductible amount disputes. For those, patients must use CID’s complaint process separately.

Emergency Care and Retroactive Prior Authorization

Federal law (the Emergency Medical Treatment and Active Labor Act, EMTALA, and the ACA) prohibits insurers from requiring prior authorization for emergency room services. If you reasonably believe you have a medical emergency, you may go to any emergency room — in or out of network — and the insurer must cover the visit at in-network levels under the No Surprises Act.

However, once stabilized, post-stabilization care often requires PA. If you’re admitted from the ER, the inpatient stay typically needs concurrent or retroactive authorization within 24–48 hours. Hospitals handle this automatically through their utilization review departments, but errors do happen — and patients sometimes receive denial letters weeks later. If this occurs, the No Surprises Act and EMTALA provide strong appeal grounds.

Retroactive PA is also available for urgent procedures that couldn’t wait for standard PA — for example, an urgent MRI ordered Friday afternoon when the insurer’s PA team won’t review until Monday. Document the medical urgency thoroughly and file the retroactive PA within 48–72 hours of the service.

Six Real Connecticut Prior-Auth Scenarios

Case 1 — Hartford diabetes patient, GLP-1 PA denial. A 54-year-old Hartford resident with type 2 diabetes (A1C 8.4) and BMI 34 was denied Mounjaro by Aetna because she hadn’t yet ‘tried’ Ozempic despite being on Trulicity for 18 months. The step-therapy exception request under PA 23-171 (citing stable failure on Trulicity) was submitted; Aetna approved within 48 hours. Annual savings versus paying cash: $13,200.

Case 2 — Stamford MRI denial. A 41-year-old Stamford executive with persistent low-back pain was denied lumbar MRI by UHC commercial plan because he hadn’t completed 6 weeks of physical therapy. Provider submitted peer-to-peer noting positive straight-leg raise, foot drop, and reflex changes — all ‘red flag’ symptoms that bypass the PT-first criterion. UHC overturned on P2P within 24 hours. MRI revealed L5-S1 disc herniation requiring urgent surgical consultation.

Case 3 — Greenwich Medicare Advantage knee replacement denial. A 72-year-old Greenwich UHC MA member was denied knee replacement because she ‘had not exhausted conservative treatment.’ She had documented 18 months of PT, three cortisone injections, and X-rays showing bone-on-bone arthritis. Internal appeal denied. CID external review overturned in 32 days, citing alignment with Original Medicare LCD on total knee arthroplasty.

Case 4 — New Haven biologic denial. A 38-year-old New Haven mother with severe psoriatic arthritis was denied Skyrizi by ConnectiCare because she hadn’t tried Humira. Step-therapy exception filed citing prior Humira failure (documented at her previous job’s plan three years earlier, records obtained from former rheumatologist). Approved in 4 days.

Case 5 — West Hartford bariatric denial. A 47-year-old West Hartford resident with BMI 42 and type 2 diabetes was denied sleeve gastrectomy by Anthem because her 6-month medically supervised weight management documentation ‘lacked monthly weight entries.’ Resubmission with reconstructed monthly weight log from MyChart vitals overturned the denial.

Case 6 — Norwich migraine CGRP denial. A 33-year-old Norwich teacher was denied Emgality by ConnectiCare for chronic migraine despite failing propranolol and topiramate. Initial denial cited ‘insufficient migraine diary.’ Provider submitted detailed clinic notes documenting 15+ headache days/month over 4 months. Approved on resubmission.

Patient Checklist: Avoid a PA Disaster

• Before any new medication, ask the provider if PA is required and how long the insurer typically takes
• Before any imaging or procedure scheduled more than 7 days out, confirm PA is on file before the appointment
• Keep a running personal log of all PA approvals, denials, and authorization numbers in a single document
• Read every denial letter immediately — appeal deadlines are short
• Always ask for the specific clinical reason and medical-necessity criteria not met
• If denied, ask your provider for a peer-to-peer review BEFORE filing a formal appeal — it’s faster
• Maintain copies of all prior therapy documentation (other plans’ EOBs, old pharmacy records) for step-therapy exception requests
• Save the CID phone number (800-203-3447) in your contacts in case you need consumer assistance
• When switching plans, get PA records from your prior plan — many new plans will honor an existing PA for the first 90 days under continuity-of-care rules
• For chronic medications, ask about 90-day mail-order fills which reduce PA renewal frequency

Mistakes That Get PAs Denied

• Submitting PA after the service has been delivered (most insurers refuse retroactive PA except in true emergencies)
• Provider’s office using generic template language with no patient-specific clinical justification
• Missing prior therapy documentation in step-therapy scenarios
• Wrong ICD-10 diagnosis code on the PA submission (must match the on-label indication)
• Patient ignoring denial letter until past the appeal deadline
• Not requesting peer-to-peer review when offered
• Filing internal appeal without the supporting medical records
• Failing to escalate to CID external review after internal appeal denial
• Switching insurance plans mid-treatment and not transferring PA documentation
• Assuming the appeal is hopeless — denial overturn rate on appeal is roughly 80% nationally

How We Find Your Insurance Helps

Antonucci, Joseph (CT License #21658409) and the team at We Find Your Insurance work alongside clients facing PA denials and step-therapy battles every week. Specifically, our services for clients dealing with PA include: (1) plan-selection consults that proactively check whether your current medications and anticipated procedures will require PA under each plan on the table, (2) coaching clients and provider offices on PA exception letter language under PA 23-171, (3) drafting CID external review requests when appropriate, (4) coordinating with HR benefits administrators to clarify self-funded plan PA requirements, and (5) recommending Medigap-plus-Original-Medicare instead of Medicare Advantage for clients with high-acuity chronic care plans where MA PA friction would create real risk.

Brokerage services for plan selection, enrollment, and ongoing PA navigation are free to consumers — commissions are paid by carriers, not clients, and are identical across all plans we represent. There is no cost or obligation to schedule a consultation. Call 860-919-9663 or visit wefindyourinsurance.com. Office: 1224 Mill Street, Building B, East Berlin, CT 06023.

Frequently Asked Questions

Frequently Asked Questions