What to Expect When You're Expecting… Insurance Prior Authorization!

A Friendly Guide for Patients Starting TMS or Esketamine (Spravato®)

We’re excited to help you get started. Insurance authorization can involve several steps and, at times, may feel more complicated than expected. This guide is here to help you understand what may happen behind the scenes while we work to obtain authorization for your treatment.

What Is Prior Authorization?

Prior authorization (sometimes called "pre-certification" or "pre-approval") is a process many insurance plans require before they agree to cover certain treatments, including TMS and Esketamine (Spravato®).

Think of it as insurance's way of saying:

"We may cover this treatment, but we first need certain clinical and coverage information before making a decision."

Our team gathers the required information, submits the necessary paperwork, and works directly with insurance so that you do not have to navigate the process alone.

Why Can It Be So Complicated?

Modern insurance plans are often made up of multiple parts that communicate with one another... sometimes better than others.

Depending on your plan, TMS or Spravato® may be reviewed under:

• Medical benefits

• Pharmacy benefits

• Behavioral health (mental health) benefits

• A combination of the above

In many cases, your insurance company works with other organizations to manage different aspects of coverage. For example:

• UnitedHealthcare may work with Optum

• Blue Cross plans may work with Carelon

• Other insurers may use separate specialty pharmacies or review companies

As a result, there may be multiple departments, systems, and organizations involved in a single authorization request.

"I Got a Denial Letter! Should I Panic?"

Usually not.

One of the most confusing parts of the process is that patients often receive insurance communications before the full review process is concluded.

Examples we commonly see include:

• A “denial” from one department because the treatment is not covered under that department (e.g. behavioral health benefits), even though it may be covered under another (e.g. medical benefits).

• A notice stating that the insurance company "never received information" when we have in fact submitted it to the appropriate department.

• A letter saying a “case has been closed” because there was no response, even though another branch of the insurance company is actively reviewing the request.

• Duplicate cases being opened by different parties (for example, our office and a specialty pharmacy), resulting in one case being approved while the duplicate case is closed.

These letters can be alarming, but they are often just one piece of a much larger process.

Why Would Insurance Deny Something First?

Increasingly, the initial review process is heavily automated.

For more complex cases, it is not unusual for an initial request to receive a denial that then requires a formal appeal or additional review.

In fact, obtaining the first denial is sometimes simply the step that allows us to move the request to the next level of review.

A denial does not necessarily mean the treatment is not covered or that the process is over.

What Should I Do If I Receive a Letter, Call, or Message from Insurance?

Please let us know as soon as possible.

Even when insurance sends us copies of communications, they do not always arrive at the same time, or at all.

If you receive:

• A letter

• A phone call

• A text message

• An email

• An explanation of benefits (EOB)

Please forward it to us or contact our team. This information may help us understand where your case stands and prevent unnecessary delays.

How Will I Know What's Going On?

We know waiting can be stressful.

Our team actively follows your case throughout the authorization process and works to resolve issues as they arise. If you opt in to our SMS communication system, we are happy to provide updates as your case progresses.

While we cannot control how quickly insurance companies process requests, we can assure you that we are monitoring the process closely and advocating for you every step of the way.

Does Authorization Mean Treatment Starts Immediately?

Not always.

Authorization is often a major milestone, but additional steps may still be required before treatment can begin.

For example:

• Specialty pharmacy processing

• Medication ordering and shipment

• Benefit verification updates

While authorization is certainly good news, it does not always mean treatment can begin the next day.

Rest assured that once authorization is received, we will continue working to complete any remaining steps and begin treatment as soon as possible.

In summary

Insurance authorization can sometimes feel confusing, contradictory, and frustrating for patients and healthcare providers alike.

The good news is that you have an experienced team on your side. Our team deals with these processes every day. We will keep you informed, advocate on your behalf, and let you know when a final decision has been reached. If approval is ultimately not granted, we will discuss the available options and next steps with you.

In the meantime:

• Don't panic if you receive confusing insurance communications.

• Let us know about any letters, calls, texts, or emails you receive.

• Sign up for SMS updates if you'd like more frequent communication.

• Reach out anytime with questions or concerns.

We're looking forward to helping you get started. The paperwork may be complicated; but we'll guide you through it.