Prior Authorization
Keeping authorisations valid from the order to the date of service.
Prior authorisation is where a great many otherwise clean claims are lost, usually because the approval expired, covered the wrong number of visits, or was never obtained at all. We run it as a tracked process: check whether it is required, submit what the payer needs, and confirm the approval still holds before the visit.
Tools we work in
- Availity
- CoverMyMeds
- payer portals
- athenahealth
- eClinicalWorks
- Epic
Works well with
Scope
What this covers
The specific work included when you engage us for this service.
- Payer and plan checks for whether an authorisation is required at all
- Submission through payer portals, electronic prior authorisation where supported, and fax where it is not
- Clinical documentation assembled to support medical necessity
- Authorisation tracking with expiry dates and visit-count limits monitored
- Peer-to-peer review scheduling where a request is denied or pended
- Re-authorisation and extension requests before a course of treatment runs out
- Retrospective authorisation requests where a payer permits them
What you receive
- 01A live authorisation tracker showing status, expiry and visits remaining
- 02Documented submission and decision history for every request
- 03A weekly list of authorisations about to expire, with the action needed on each
Questions
Prior Authorization, answered
Are prior authorisations getting easier?
Slowly, and mostly on the pharmacy side. The CMS interoperability and prior authorisation rule is pushing payers toward FHIR-based APIs, which should reduce portal and fax work over time, but today much of the process is still manual and payer-specific. We plan for the manual path and use electronic routes only where a payer actually supports them rather than where a brochure says they do.
What happens if the payer denies the authorisation?
A denial is not always final. Depending on the payer we can request a peer-to-peer review, supply additional documentation, or file an appeal. Where a procedure has already happened, some payers allow a retrospective authorisation and others do not. We tell you which route applies before spending time on it, because pursuing an unavailable path is the most common wasted effort here.
Can we pay to get an authorisation approved faster?
Not in the way people usually mean. There are expedited review processes for urgent cases, but they are defined by the payer and by clinical urgency rather than by payment. We will use an expedited request where the clinical situation qualifies and standard review where it does not, because misusing the expedited route tends to create friction with the payer later.
Most often requested by
Related
More in Healthcare
AI Medical Billing
The billing cycle run end to end, with automation where it earns its place.
Revenue Cycle Management
The whole cycle, from patient scheduling to the final payment.
Medical Coding
Diagnosis and procedure codes that match the documentation.
Denial Management & Appeals
Working denials by cause, inside the payer's deadline.
Tell us where the manual work is
A 30-minute call. We map the process, tell you what we would automate or build first, and what it costs. No retainer before you agree the scope.
- No retainer before scope is agreed
- Written plan you can act on alone
- Worldwide delivery, on your hours