How prior authorization works, which services usually need it, and a simple process for requesting, tracking and renewing authorizations without denials.
Prior authorization is a payer's approval, given before the service, that it will consider paying for a specific treatment. It is not a guarantee of payment, but without it the claim will almost certainly be denied, and those denials are among the hardest to overturn.
Which services usually need authorization?
It depends on the payer and plan, but these categories often do:
- Advanced imaging such as MRI, CT and PET scans.
- Surgical and specialty procedures.
- Physical, occupational and speech therapy beyond an initial number of visits.
- Behavioral health services, especially intensive programs and psychological testing.
- Durable medical equipment such as power mobility devices.
- Specialty and high-cost medications.
Always check the specific plan. Two plans from the same payer can have different requirements, and many payers delegate authorization to a separate utilization management company.
A process that works
1. Check requirements when the service is ordered
The moment a service is ordered or scheduled, check whether this plan requires authorization for this code. Waiting until the day before leaves no time to get an answer.
2. Submit with complete documentation
Most delays and denials of authorization requests come from missing clinical information. Include the diagnosis, relevant history, prior treatments tried and the provider's rationale.
3. Follow up on a schedule
Pending requests do not move on their own. Check status on a fixed schedule and record every contact with a reference number.
4. Record the approval as data
Store the authorization number, approved codes, number of units or visits, and start and end dates against the patient, not in a fax folder. Then your schedule can warn you when a visit falls outside the authorization.
5. Renew before it runs out
For ongoing care, request the next authorization before the current one expires or its visits are used up.
6. Escalate denials quickly
If a request is denied, ask whether a peer-to-peer review with the payer's medical reviewer is available. It is often the fastest way to reverse a decision.
Common mistakes
- Authorizing one CPT code and performing a different one.
- Treating past the authorized number of visits.
- Getting the authorization under the wrong provider or location.
- Assuming an authorization from the old plan carries over after a plan change.
How GetMax helps
GetMax keeps authorizations on the patient and appointment, counts visits used against visits approved, and alerts your team before an authorization expires. Our prior authorization service can handle requests and follow-up for you.
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