Objective :

Oversee and coordinate the prior authorization (PA) process to ensure required approvals for medical services, procedures, medications, and durable medical equipment (DME) are obtained in a timely manner, preventing delays in care and avoiding claim denials.

Key Responsibilities :

Authorization Requirement Verification :

  • Identify whether the ordered service, medication, or procedure requires prior authorization by:
  • Reviewing payer-specific guidelines
  • Using web portals or clearinghouse tools
  • Contacting payers directly when needed
  • Confirm whether the provider is in-network to determine the correct PA process.

Authorization Request Submission:

  • Collect necessary documentation for submission:
  • Provider order/referral
  • Clinical notes, diagnostics, or medical necessity justifications
  • CPT/HCPCS and ICD-10 codes
  • Submit PA requests via:
  • Insurance payer web portals (e.g., Availity, NaviNet, UHC, Aetna portals)
  • Fax or phone when electronic options are unavailable
  • EHR-integrated prior authorization tools (if applicable)

Follow-Up & Status Tracking:

  • Track submitted requests daily or per urgency level.
  • Follow up with payers to:
  • Confirm receipt
  • Clarify missing documentation
  • Expedite urgent requests when medically necessary
  • Record authorization number, approval/denial status, effective dates, and any limitations.

Communication & Documentation :

  • Notify the clinical team of approval or denial outcomes.
  • Inform the billing team of any service restrictions or auth numbers required for claims.
  • Update the patient if the procedure is denied or delayed due to payer issues.
  • Ensure documentation is entered into the EHR for audit trail and billing use.

Appeals and Resubmissions :

  • If denied, coordinate with the provider to:
  • Submit additional documentation
  • Initiate a peer-to-peer review
  • File a formal appeal with the payer
  • Track appeal outcomes and communicate with all stakeholders.

Our Best Practices :

  • Use a prior authorization tracking log or software to monitor turnaround times.
  • Maintain a payer-specific matrix of services that typically require authorization.
  • Standardize workflows and create templates for submission cover sheets.
  • Flag authorization deadlines and expirations to avoid missed windows.
  • Train clinical and admin staff on medical necessity documentation requirements.

Why It’s Important :

A well-managed prior authorization process reduces care delays, improves patient satisfaction, and prevents claim denials due to missing or invalid authorizations — all critical to both operational and financial performance.