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Prior Authorization Services

When a payer requires prior authorization and none is on file, the claim is usually denied, and approval after the fact is rarely granted. We check requirements for each scheduled service, submit requests with the clinical information payers ask for, follow up until there is a decision, and make sure the approval matches what is billed.

  • Requirements checked per payer, plan and CPT code
  • Requests submitted through payer portals and benefit managers
  • Approval number, codes, units and dates matched to the claim
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What our authorization team handles

  • Requirement checks

    For each scheduled service we confirm whether the specific plan requires authorization, and whether the request goes to the payer or a delegated benefit manager.

  • Clinical packet preparation

    Relevant notes, prior treatments tried, imaging and test results are assembled against the payer's published criteria, whether its own policy or a commercial criteria set.

  • Submission and status tracking

    Requests are filed by portal, fax or phone, and every pending case is checked until a decision is issued.

  • Peer-to-peer coordination

    When a request is denied or pended, we arrange the peer-to-peer discussion between your provider and the payer's reviewing physician and prepare the case summary.

  • Authorization appeals

    Adverse decisions are appealed in writing within the plan's deadline, with additional clinical support where it exists.

  • Visit and unit tracking

    Approvals that cover a set number of visits or units, common in therapy and infusion, are tracked so renewals are requested before they run out.

Our authorization workflow

  1. Step 1: Look ahead on the schedule

    Upcoming procedures, imaging and infusions are pulled from your schedule in advance. We typically look 1 to 2 weeks ahead.

  2. Step 2: Check and submit

    Requirements are checked and complete requests submitted the same day the need is found.

  3. Step 3: Follow up to a decision

    Pending requests are chased until approved or denied; urgent cases are flagged for expedited review.

  4. Step 4: Release to billing

    The approval number, approved codes and date range are attached to the encounter so the claim matches the approval.

Who needs authorization support

  • Imaging and cardiology

    Advanced imaging is one of the most frequently managed service categories.

  • Surgical practices

    Elective procedures often need approval for the procedure, the facility and sometimes the implant.

  • Oncology and infusion

    Drug therapies need approval by drug, dose and cycle, and approvals expire.

  • Therapy practices

    Physical, occupational and speech therapy plans often require approvals tied to visit counts.

Prior authorization rules are changing

For Medicare Advantage, federal rules require a decision on an expedited prior authorization request within 72 hours and, for items and services under the prior authorization rules, on a standard request within seven calendar days, and a denial notice must state the specific reasons. The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) extends decision timeframes to other payers, including Medicaid and CHIP; we track the current requirements for each payer type.

Separately, CMS rules for Medicare Advantage require plans to follow Traditional Medicare coverage rules, including national and local coverage determinations, and keep an approved authorization for a course of treatment in effect while the treatment remains medically necessary, so care is not interrupted. Several states, including Texas, have also passed "gold card" laws that exempt high-approval providers from some requirements. These rules help, but they do not remove authorization work, so tracking remains essential.

Official sources: eCFR: 42 CFR 422.568 (standard organization determinations) (external site), eCFR: 42 CFR 422.572 (expedited organization determinations) (external site), eCFR: 42 CFR 422.101 (basic benefits and coverage rules) (external site), eCFR: 42 CFR 422.112 (access to services) (external site)

Frequently asked questions

What is the difference between a prior authorization and a referral?

A referral is a primary care provider's permission for a patient to see a specialist, mostly required by HMO-style plans. A prior authorization is the payer's own approval that a specific service is medically necessary before it is performed. A visit can need both, either or neither.

Can authorization be obtained after the service?

Sometimes, but rarely for scheduled care. Some payers accept retroactive requests for urgent or emergency situations within a short window; for elective services a missing authorization usually means a denial the patient cannot be billed for under most contracts.

What is a peer-to-peer review?

It is a call between the treating provider and the payer's physician reviewer to discuss a request that has been denied or is about to be. It is often the fastest way to overturn a decision, and it goes best when the provider has a short summary of the clinical facts at hand.

Does an approved authorization guarantee payment?

No. The claim still has to match the approved service, dates and units, the patient must be eligible on the date of service, and benefits such as deductibles still apply. An approval removes one reason for denial, not all of them.

How far ahead should requests be submitted?

As soon as the service is ordered. Standard decisions can take days, and a request that needs more information can take longer, so last-minute submissions are the main cause of rescheduled procedures.

Related services and specialties

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