When your PlushCare doctor prescribes a medication or treatment that your health plan won’t cover without approval, the PlushCare prior authorization process is handled primarily by the clinical team: your provider documents why the treatment is medically necessary and submits the request to your insurer, while your job is to supply accurate insurance information and respond quickly if more documentation is needed. If you get stuck at any point, PlushCare’s support line is (800) 221-5140 or info@plushcare.com.
A prior authorization is simply your insurer’s way of confirming that a prescribed medication or treatment is medically necessary before agreeing to pay for it. The outcome often turns on details you control: the insurance data your provider submits with the request, and the clinical history your provider knows about.
What You Need to Give Your Provider
Have your insurance card in front of you before the telehealth visit. A single transposed digit can bounce a request back weeks later for reasons that have nothing to do with whether the medication is right for you.
- Member ID and group number, which identify your specific plan and employer group.
- BIN and PCN codes. The BIN is a six-digit code that routes your pharmacy claim to the correct Pharmacy Benefit Manager; the PCN narrows it to the department that manages your plan’s rules. If either is wrong, the pharmacy gets a hard denial rather than a request for more information.
- The name of your Pharmacy Benefit Manager, if your plan uses one (Express Scripts and CVS Caremark are common examples).
- Your PlushCare doctor’s NPI is included on the submission automatically, but it helps to recognize the term if your insurer references it in correspondence.
Insurance logistics are only half of the request. The clinical side matters just as much. Your provider assigns ICD-10 diagnosis codes that translate your condition into the standardized language insurers use to evaluate medical necessity. If you have tried other medications for the same condition and they did not work, or caused side effects, say so explicitly. That history of failed treatments, known as step therapy documentation, is often the deciding factor when an insurer is weighing whether to approve a non-preferred or higher-cost drug.
Recent lab results, imaging reports, or specialist notes also strengthen the request. If you’ve had relevant tests done outside PlushCare, upload them to your patient portal or bring them to the appointment. The more concrete evidence the provider can attach, the less room the insurer has to claim the treatment isn’t justified.
How the Request Reaches Your Insurer
PlushCare’s clinical team usually submits prior authorization requests electronically through the insurer’s provider portal or by secure fax to the plan’s clinical review department. Some insurers also accept submissions through third-party platforms like Availity or CoverMyMeds.
Once the request is transmitted, the insurer’s system generates a reference or tracking number. Ask your PlushCare provider’s office for that number. It’s your key to checking the status on your insurer’s member portal or automated phone system. Without it, you’re stuck on hold waiting for a representative to pull up your file manually.
How Long the Insurer Has to Decide
Starting January 1, 2026, the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) requires impacted payers to issue a decision within 72 hours for expedited requests involving urgent medical needs, and within seven calendar days for standard, non-urgent requests for medical items and services.1Centers for Medicare & Medicaid Services. CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Authorization Process Those timelines apply to Medicare Advantage, Medicaid, CHIP, and plans on the federal exchange. Private employer plans may follow different state-level rules.
If your situation is medically urgent, say because you need a medication to prevent a serious deterioration in your health, ask your provider to flag the request as expedited so the 72-hour clock applies instead of the seven-day one.
State laws sometimes impose tighter deadlines than the federal floor. Several states require decisions on prescription drug authorizations within 72 hours even for non-urgent requests, and some mandate 24-hour turnaround for urgent cases. Your insurer’s explanation of benefits or member handbook should spell out which timeline governs your plan.
Checking the Status of Your Request
After the request goes in, the insurer reviews the clinical documentation against your plan’s coverage criteria. You can track progress in several ways:
- Log into your insurer’s member portal and look for an “authorizations” or “claims” section. Most portals show whether a request is pending, approved, or denied.
- Call the number on the back of your insurance card and enter your reference number at the automated prompt. The system usually reads back the current status without a live representative.
- Send a message through PlushCare’s patient portal asking the care team for an update. They can check whether the insurer has responded on their end.
If the insurer needs additional documentation, more lab results, a letter of medical necessity, or clarification on your treatment history, they’ll notify both you and your provider. Respond quickly. Delays in supplying supplemental information can push the review past the decision deadline and effectively reset the clock.
If Your Request Is Denied
A denial is not the end. Denials typically trace to missing clinical documentation, the medication not being on your plan’s formulary, an unmet step therapy requirement, incorrect diagnosis or procedure codes, or the insurer concluding that medical necessity wasn’t demonstrated. Each of those is addressable.
Ask for a Peer-to-Peer Review First
Before filing a formal appeal, your PlushCare provider can often request a peer-to-peer review, a phone call between your prescribing doctor and the insurer’s medical director. The call usually runs five to ten minutes and lets your provider explain, in clinical terms, why the prescribed treatment fits your situation. This is where thorough documentation of failed alternatives and current symptoms pays off.
Scheduling these calls can be frustrating. Insurers sometimes offer windows as short as 24 hours from the denial, and reaching the reviewer may involve long hold times. If your provider agrees the medication matters, press for this call early. A successful peer-to-peer can flip a denial to an approval without any formal paperwork.
File an Internal Appeal
Federal law gives you at least 180 days from the date of a denial notice to file an internal appeal with your insurer.2eCFR. 29 CFR 2560.503-1 – Claims Procedure You can file by completing the insurer’s appeal form, or by writing a letter that includes your name, claim number, and insurance ID. Attach anything that supports your case: a letter from your provider explaining medical necessity, updated lab work, or documentation of side effects from alternative medications.3HealthCare.gov. Internal Appeals
For prior authorization denials specifically, the insurer must respond to an internal appeal within 15 days.3HealthCare.gov. Internal Appeals If your situation is urgent, you can request an expedited internal appeal, and the insurer must respond as quickly as the situation requires.
Request an External Review
If the internal appeal is denied, you have the right to an independent external review, a fresh evaluation by a reviewer outside your insurance company. File this request in writing within four months of receiving the final internal appeal denial. External review is available for any denial involving medical judgment, a determination that a treatment is experimental, or a cancellation of coverage based on alleged misrepresentation in your application.4HealthCare.gov. External Review
Standard external reviews must be decided within 45 days. Expedited external reviews, for situations where a delay would seriously jeopardize your health, must be decided within 72 hours or less. If your plan uses the HHS-administered federal external review process, there is no charge. State-run or independent review organization processes can charge up to $25.4HealthCare.gov. External Review
Step Therapy Exceptions
Step therapy requires you to try and fail on a cheaper or preferred medication before the insurer will cover the one your doctor actually prescribed. If your provider believes the preferred drug is inappropriate for you, because of a known allergy, a contraindication, or because you’ve already tried it outside the insurer’s records, they can request a step therapy exception. This is a specific type of prior authorization request that argues you should skip the first-step drug entirely.
The exception follows the same general submission process, but documentation needs to be more targeted. Your provider should explain why the preferred alternative is medically inappropriate, cite clinical evidence supporting the prescribed drug for your condition, and include records of prior treatment failures if they exist. CMS defines step therapy as a process that “begins medication for a medical condition with the most preferred drug therapy and progresses to other therapies only if necessary.”5Centers for Medicare & Medicaid Services. Medicare Advantage Prior Authorization and Step Therapy for Part B Drugs The exception exists because that progression doesn’t make clinical sense for every patient.
Renewing an Approved Authorization
Approvals don’t last forever. Initial approvals often cover one to six months, after which the insurer requires a renewal (sometimes called reauthorization) to confirm the medication is still working and still medically necessary. Specialty drugs tend to get shorter initial windows so the insurer can reassess sooner.
Your provider needs to submit renewal documentation before the current authorization expires. If it lapses, the pharmacy can’t fill your next refill until a new authorization goes through, which can leave you without medication for days or weeks. Set a reminder about a month before your authorization end date.
Renewal submissions should include more than a repeat of the original request. Your provider should attach updated clinical notes showing how you’ve responded to the medication, relevant lab values compared against your pre-treatment baseline, and a rationale for continued therapy. Evidence of measurable improvement, even modest improvement, strengthens the renewal considerably. If the medication is maintaining your condition rather than actively improving it, the provider should document what would likely happen without continued treatment.