Guidelines for How Insurance Coverage and Prior Authorizations Work

So, most of us don’t know how the process of getting supplies, repairs, or even a new orthosis or prosthesis works. This isn’t something to feel badly about, it’s just that we’re all conditioned to think that since we have insurance, everything should just go smoothly! Unfortunately, this isn’t the case in most instances.

Most insurance companies use Medicare guidelines as their own, so this post will directly reference those guidelines. The other aspect we’ll be explaining is prior authorizations, which Medicare does not do but companies like Coordinated Care and Kaiser Permanente do. If you have questions about whether or not your insurance requires prior authorizations, you can always call the customer service number on the back of your insurance card.


For any repair, supply order, or new/replacement device, you need the following:

  • Recent chart notes that reference your need for any of the above. Recent means within the last 6 months and they absolutely have to reference your need for supplies, repair, or new/replacement device.

    • If your notes do not reference your need, your insurance company can refuse payment and even at times can audit the claim. When a claim is audited, they research to make certain all the guidelines have been met. If they have not been met, then the payment is taken back and the patient is then responsible for the cost.

  • Current prescription from your primary care doctor (PCP). An initial RX is good to have on file and we also send them a detailed, Medicare compliant RX/certificate of medical necessity to sign and return after we have seen you.

    • Both the initial RX and the one we send are important. These outline a timeframe for your insurance company to see the need for what we are providing for you.

Once the timeline and need are established, we can continue the process of providing what you’ve asked for. It is essential that these steps are followed to help ensure we’re doing everything we can to lessen the chances of our patients needing to pay for the services out of pocket.

If your insurance is one that requires prior authorization, there is an additional step to the process before we are able to deliver your supplies, complete your repair, or give you the new/replacement device you’ve come in for. That step is as follows:

The 2 steps above must be completed before this one:

  • Once we have both the chart notes from your doctor and the detailed prescription, we then contact your insurance company to start the prior authorization process.

    • This can be over the phone, online, or by filling out a form and faxing it to your insurance company.

  • For all prior authorization requests, all insurance companies require chart notes from your primary care doctor (PCP) and a prescription to be submitted at the same time as the request.

    • Once the request is submitted, the authorization can take up to 2 weeks (sometimes 3 weeks) before we receive either a confirmation or a denial.

  • Upon receipt of authorization, we can then continue the process of completing the repair, filling your supply order, or delivering your new/replacement device.

These steps help ensure that you, the patient, are not stuck with paying out of pocket for what your insurance should be covering. We want to do everything we can to keep your care affordable and consistent.