Hassle-free prior authorization management to ensure services are approved before care.
Prior authorization is one of the most time-consuming and frustrating aspects of medical practice management. Insurance companies require pre-approval for many services, and obtaining these authorizations often involves lengthy phone calls, complex documentation, and persistent follow-up. Our prior authorization team handles the entire process so your staff and providers can focus on patient care.
What’s Included:
Authorization Requirement Identification:
- Comprehensive payer-specific authorization requirement databases
- Service-specific authorization needs by CPT code
- Automatic flagging during scheduling and eligibility verification
- Authorization requirements by plan type (HMO typically requires more)
- Procedure-specific authorization lead time identification
- Emergency vs. non-emergency authorization pathways
Clinical Documentation Review:
- Review of provider documentation for medical necessity support
- Identification of missing information needed for authorization
- Clinical note enhancement suggestions for stronger approvals
- Diagnosis code verification supporting medical necessity
- Previous treatment documentation compilation
- Clinical trial failure documentation for step therapy requirements
- Supporting lab results, imaging reports, and specialist notes
Authorization Request Submission:
- Electronic authorization submissions through payer portals
- Phone-based authorization requests with live representatives
- Fax submissions with comprehensive supporting documentation
- Completion of payer-specific authorization request forms
- Clear presentation of medical necessity rationale
- Alternative treatment documentation when required
- Provider specialty and qualification verification
Comprehensive Documentation Submission:
- Complete medical records relevant to authorization request
- Lab results, imaging reports, and diagnostic test results
- Previous treatment history and outcomes
- Failed conservative treatment documentation
- Clinical guidelines and evidence-based medicine references
- Manufacturer prescribing information for medications
- Peer-reviewed studies supporting proposed treatment
Payer Follow-Up & Tracking:
- Daily status checks on pending authorizations
- Direct contact with payer authorization departments
- Escalation to supervisors for delayed authorizations
- Reference number tracking for every authorization
- Approval or denial notification within 24 hours of decision
- Authorization timeline tracking and deadline monitoring
- Systematic follow-up every 24-48 hours until resolution
Urgent & Expedited Requests:
- Identification of urgent medical necessity
- Expedited review requests for time-sensitive cases
- Same-day authorization efforts for urgent procedures
- Emergency authorization protocols (72-hour post-service)
- Direct physician-to-physician (peer-to-peer) coordination
- Hospital admission and emergency department authorizations
Denial Management & Appeals:
- Immediate appeal preparation for denied authorization requests
- Additional clinical documentation gathering
- Peer-to-peer review scheduling with medical directors
- Step therapy documentation and completion
- Alternative treatment authorization when primary is denied
- Multi-level appeal processing (first, second, external review)
- State insurance commissioner complaints when appropriate
Authorization Tracking System:
- Centralized database of all authorization requests
- Authorization number and date issued recording
- Number of authorized units/visits/days
- Authorization expiration date tracking
- Service-specific limitations and restrictions
- Units used vs. remaining authorized units
- Expiration alerts and renewal notifications
Renewal & Extension Management:
- Proactive renewal requests before authorization expires
- Ongoing treatment medical necessity updates
- Progress note documentation for continued need
- Extension requests for inpatient stays
- Additional units/visits requests based on clinical need
- Retroactive authorization attempts when needed
Provider & Patient Communication:
- Immediate notification to providers when authorizations are approved
- Patient notification of authorization status
- Scheduling coordination once authorization is obtained
- Denial communication with alternative options
- Authorization-on-file confirmation before service delivery
- Clear documentation in patient charts and schedules
Authorization Types We Handle:
- Inpatient hospital admissions
- Outpatient procedures and surgeries
- Diagnostic imaging (MRI, CT, PET scans)
- Durable medical equipment (DME)
- Physical therapy and rehabilitation services
- Home health services
- Specialty medications and infusions
- Behavioral health services
- Specialty referrals and consultations
- Pain management procedures
Response Time:
- Routine authorizations: 3-5 business days
- Urgent authorizations: 24-48 hours
- Stat/emergency: Same-day efforts with immediate follow-up
Benefits:
- Prevent claim denials due to missing authorizations
- Reduce patient care delays and appointment cancellations
- Increase authorization approval rates through thorough documentation
- Free clinical staff from hours of phone calls and paperwork
- Improve patient satisfaction with smooth scheduling
- Maintain compliance with payer authorization policies
- Reduce authorization-related claim write-offs
Success Metrics: 85-90% authorization approval rate on first submission