Prior authorization
Prior authorization is payer approval, obtained before a procedure, drug, or service is delivered, required to get the claim paid at all.
Follows eligibility and benefits verification. Feeds into medical coding.
Where practices lose money here
Authorization requirements missed
Not every payer requires authorization for the same procedure, and missing one on a high-dollar service means the entire claim can be denied with no appeal path.
Authorized units run out silently
A visit authorization approved for a set number of units gets used past its limit without anyone tracking it, and claims start denying for lack of coverage on units the practice assumed were approved.
How we handle it
Check payer-specific authorization requirements for each procedure and high-cost drug before it is scheduled.
Submit requests through payer portals or by phone, whichever the payer requires, with clinical documentation packaged to match medical necessity criteria.
Schedule and prepare for peer-to-peer reviews when a payer’s initial determination requires physician-to-physician discussion.
Track authorization numbers, approved unit counts, and expiration dates against what is actually delivered during treatment.
Monitor expiring authorizations and initiate renewal requests before the current approval lapses.
What you receive
Concrete output for this step, delivered on a set schedule rather than on request.
- An authorization tracker showing status, approved units used, and expiration date for every open case.
- An expiring-soon report generated weekly.
Where this sits in the cycle
Authorization has to be secured before the service is delivered. Once treatment happens without it, there is often no way to recover the claim after the fact, which makes this one of the highest-stakes steps in the cycle.
Questions about this step
How do you know which procedures need authorization?
We maintain payer-specific authorization requirement lists by CPT code and update them as payer policy changes, rather than relying on a static list.
What happens if a peer-to-peer is required?
We schedule it and prepare a summary of the clinical documentation for the provider ahead of the call, so the provider walks in ready rather than scrambling.
Want us to review how this is handled in your practice right now?
The free billing audit looks at prior authorization alongside the rest of the cycle, and comes back with specific findings.