Florida Blue’s approach to prior authorizations

May 12, 2025

As a health insurance provider, Florida Blue’s primary goal is to ensure that our members receive safe, evidence-based, and affordable care. One way we achieve this is through our prior authorization process. Prior authorization is a valuable tool that protects our members and promotes high-quality care. In this blog post, we'll explore the benefits of prior authorization and clarify a few common misconceptions.

What is prior authorization?

A prior authorization is when a health care provider asks us to confirm coverage and approve a treatment or medication before it's given to a patient. This is different from a claim, which is a request for payment after the treatment or service is provided. Think of it like this: a prior authorization is a request for treatment before a service, while a claim is submitting a bill for the treatment after it's been completed.

Streamlining the prior authorization process

At Florida Blue, we want to make health care easier and as affordable as possible for our members. One way we're doing this is by streamlining the prior authorization process. We're using Artificial Intelligence (AI) and advanced technology to speed up and improve the process. Since 2022, we’ve processed over 2.5 million pre-approvals with a median response time of just 19 seconds.*

Benefits of prior authorization

Prior authorization offers several benefits, including:

1. Ensures members get the right care: We review treatments, medications, and procedures to ensure they're supported by evidence-based, clinical guidelines. This reduces the risk of members receiving unnecessary or ineffective care.
2. Keeps members safe: We protect members from potentially unsafe or experimental treatments by having a health care professional review certain requests before proceeding.
3. Saves members money: Prior authorizations help prevent members from being billed for expensive treatments that may not be covered by their plan and promote evidence-based, cost-effective alternatives.
4. Supports health insurance affordability: Prior authorizations reduce fraudulent claims, keeping health care costs more manageable for all members in the plan.

The facts about prior authorization at Florida Blue

Here are some surprising facts about prior authorization at Florida Blue:

• Only 8% of medical and pharmacy claims we receive are reviewed through the prior authorization process, streamlining the process for health care providers and patients.*
• 90% of prior authorizations are reviewed and approved in seconds, supported by automation and AI solutions.*
• AI cannot deny a prior authorization request. If the AI system is unable to approve a request at Florida Blue, it's forwarded to a specialist for further review. This ensures that every request receives a thorough review by a qualified medical or pharmacy specialist if needed.
• For denied authorizations, members have the right to appeal, and in certain cases, can request a federal external review.

In conclusion, prior authorization is a valuable tool that protects our members and promotes high-quality care. By understanding the benefits and facts about prior authorization at Florida Blue, we hope to dispel common misconceptions and provide our members with peace of mind.

*Based on internal data
A prior authorization is not a guarantee of payment. Deductibles, coinsurance, and copays may still be applicable.