What to do
Ask the clinic the question directly
"Are you submitting the prior authorization, or am I?" Ask it early, ask it of the person who actually does the paperwork rather than the person at the front desk, and get a name. Surgical coordinators and prior-authorization specialists exist at most practices and are the people who know.
If the CLINIC submits, your job is verification, not paperwork
Get the submission date, the reference number, and a copy of what was sent, including the letters. You are entitled to know what was submitted on your behalf, and reading it is how you find the criterion nobody answered.
If YOU submit, get the plan's own form and its checklist
Ask the plan what form it wants, what must accompany it, and where it goes. Send it so you can prove arrival, and follow up in a week rather than a month.
Either way, keep your own copy of everything
Clinics change staff and plans lose faxes. The person with the complete file is the person who can answer a question quickly, and that should be you.
The usual split, by what you are asking for
None of this is a rule, and your plan may do it differently. It is a starting point for the question rather than an answer to it.
- SURGERY: the surgeon's office almost always submits. Your job is the criteria, the letters, the confirmation of receipt, and the clock.
- HORMONES AND OTHER MEDICATION: the prescriber submits, usually triggered by a pharmacy rejection. The rejection code tells the prescriber what the plan wants.
- OUT-OF-NETWORK OR A GAP EXCEPTION: frequently you, or you and the clinic together, because it is an argument about the network rather than about the medicine.
- ELECTROLYSIS AND HAIR REMOVAL: varies more than anything else. Often the provider does not deal with insurance at all and you are submitting for reimbursement afterwards, which is a different process with its own deadline.
- REIMBURSEMENT AFTER PAYING: always you. Ask for the claim form and the timely-filing deadline in the same message.
Why this matters more than it sounds
When the clinic submits, the request is written by people who do this every week and know the plan's habits. That is genuinely good. What they do not have is your plan document, your appeal history, or a reason to care about a criterion that will only bite in eight weeks.
So the division of labour that works is: they write the clinical case, you supply the plan's own words and make sure the process happened. Neither half works alone, and the half that gets dropped is almost always yours, because nobody told you it was yours.
Common questions
- My surgeon's office says they handle everything. Should I just leave it to them?
- Leave the clinical writing to them and keep the verification for yourself. Ask for the submission date and reference number, and read the letters before they go if you can. The people who get surprised are the ones who assumed silence meant progress.
- Nobody at the clinic seems to know who does this.
- Ask for the prior-authorization coordinator or the surgical scheduler by title. If the practice genuinely has nobody, that is worth knowing early, because then the chasing is yours by default and it starts now rather than in three months.
Where to go next
Sources for the legal points on this page
Also on this page, without a citation yet
- Which party submits a given request. This page describes how it usually works across plans and services; your plan and your clinic set the actual process. Both will tell you if you ask, and the answer belongs in writing.
These are specific and checkable and we have not yet checked them against a primary source. Treat them as a starting point rather than as settled, and do not put them in an appeal without confirming them.