Key takeaways
- Know each payer's authorization rules for your common services.
- Send complete clinical information the first time to avoid delays.
- Track approved visits and dates, and match the claim to the approval.
Prior authorization is the payer's approval before a service is performed. When it is required and missing, the claim usually denies, and appeals for missing authorization are hard to win. For busy practices, the goal is a repeatable process that catches authorization needs early and tracks them until the visit.
Step 1: Know when authorization is required
Rules differ by payer, plan, service, and setting. Common examples include imaging, procedures, injections, therapy beyond a set number of visits, some specialty drugs, and certain behavioral health services. Medicare Advantage and Medicaid managed care plans often have their own lists that differ from original Medicare.
- Keep a current reference of authorization rules for your top payers.
- Check the rules for each new patient and each new service, not just the first visit.
- Watch for payer policy updates, which can add or remove services from the list.
Step 2: Gather what the payer needs
- Patient and insurance details, including member ID and group.
- Ordering and rendering provider information, with NPIs.
- Diagnosis codes and the planned procedure or service codes.
- Number of visits or units requested, and the date range.
- Clinical notes that show why the service is needed, such as history, prior treatment, and test results.
Step 3: Submit and record
Submit through the payer portal, by phone, or by fax, depending on the payer. Record the submission date, the reference number, and the expected response time. If the request is pending, set a follow up date.
Step 4: Track what was approved
An approval is not open ended. It usually covers specific codes, a set number of visits or units, and a date range. Track the approved number and the dates, and alert the team before the patient runs out of authorized visits.
Step 5: Match the claim to the authorization
The claim should include the authorization number where required, and the billed codes, units, and dates should fall within what was approved. A mismatch can deny even when an authorization exists.
Step 6: Handle denials quickly
If an authorization is denied, find out why. Sometimes the payer needs more clinical information, and a peer to peer review with the payer's reviewer may be available. If a claim denies for missing authorization, check whether the payer allows retroactive authorization in that situation before you appeal.
Keep authorization status visible to the scheduling team. Most authorization denials happen because the person booking the visit did not know approval was missing or used up.
Questions to ask your team
- Which services most often deny for missing authorization?
- Where are approved visits and dates recorded, and who checks them before scheduling?
- How long do requests usually take with each of your top payers?
Where Afiable helps
Afiable checks authorization requirements before the visit, prepares and submits requests, tracks approvals and remaining visits, and flags what your team needs to know each day. Book a free audit and we will review your recent authorization denials and show you where the gaps are.
Questions practices ask
Can authorization be obtained after the visit?
Some payers allow retroactive authorization in limited situations, such as emergencies. Many do not. Check payer policy before relying on it.
Who should own authorizations in a practice?
One clearly named person or team, with visibility for schedulers, so nobody books a visit without knowing the authorization status.
This article is general information for practice owners and managers. Payer policies and regulations change, so confirm current rules with each payer before acting.