Prior Authorization Services

Prior authorization services

Prior authorization is the payer's approval, before a service is delivered, that it will be covered for this patient.

See where claims are getting stuck. No patient data needed.

We find which services need it under each plan, submit the request with the clinical documentation the payer asks for, chase it to a decision, and keep the authorization number, approved units and dates attached to the visit and the claim.

This work happens before a claim exists. Buy it on its own or pair it with our other billing services, stage by stage.

Last reviewed October 21, 2026 by the Remitwright billing team. Editorial policy

What prior authorization covers

A payer-by-payer list of which CPT and HCPCS codes need authorization under each plan you bill, kept current as payers change it

Requests submitted through payer portals, Availity, fax or phone, with the clinical notes, orders and codes the payer requires attached first time

Status chased on a logged next-action date until there is a decision, with escalation when a payer sits past its own turnaround standard

Authorization number, approved codes, units, date range and visit count recorded on the appointment and carried to the claim

Unit and date tracking so a renewal is requested before the authorization runs out, not after a denial

Retro-authorization requests where the payer allows them, and peer-to-peer scheduling for your clinician when a request is refused

Denials for missing or mismatched authorization (CO-197, CO-15) traced to cause and fixed at the root

A list on your weekly report of open requests, approvals, refusals and authorizations nearing their end date

What goes wrong when prior authorization is skipped

The authorization that did not match the claim

The authorization was for three units; four were billed. Or it covered 97110 and the clinician delivered 97140. The payer denies the line with CO-197, and because the service was already delivered there is no going back. Matching the authorization to the plan of care before the visit is the only fix that works.

The expired authorization

A behavioral health plan approved twelve sessions through the end of June. Session thirteen was in the first week of July. Nobody tracked units or dates, so the renewal request went in after the denial, and this payer does not grant retro-authorization. Two sessions go unpaid, and the clinician delivered them in good faith.

The request that never got a decision

Submitted, acknowledged, then nothing. Without a follow-up date on it, the request sits at the payer for a month while the patient waits or the practice delivers unauthorized care. Chasing open requests is dull. It is also where the money is.

How we run prior authorization

Map the rules

We build the authorization matrix for your payers and codes, using payer provider manuals and your own denial history as the starting point.

Catch the need early

Eligibility checks flag the services that need authorization. Orders and plans of care are reviewed against the matrix before the visit is scheduled wherever the workflow allows.

Submit complete

Your biller gathers the documentation the payer lists, submits through the fastest channel for that payer, and logs the reference number.

Chase and record

Open requests are followed up on their logged next-action dates. Approvals are recorded with units and dates; refusals go back to the clinician with the payer's reason and the peer-to-peer option.

Renew before it runs out

Units and date ranges are tracked. Renewals go in with enough lead time for the payer's turnaround, with the updated plan of care attached.

What you receive every week

Authorization matrix

Which codes need authorization for which plans, with the submission channel and typical turnaround, updated as payers change their lists.

Open authorization log

Every request with its status, reference number, next follow-up date and the person it is waiting on. Shared with your clinical team so nobody delivers unauthorized care by accident.

Weekly line in your report

Requests submitted, approved, refused and nearing their end date, plus any authorization-related denials with their cause.

Worked example: the ABA renewal

A hypothetical ABA practice holds a Medicaid managed care authorization for 97153 at forty units a week through March 31. On March 10 the biller's tracker shows three weeks left and a renewal that needs an updated treatment plan. The BCBA finishes the plan on March 14; the request goes in on March 15 with the plan attached; the MCO approves on March 26. Sessions continue without a gap. Had the request started on April 1, two weeks of sessions would have been unauthorized, and this MCO does not back-date.

Questions about prior authorization

Which services usually need prior authorization?

It depends on the payer, but common ones are advanced imaging, surgical procedures, DME, specialty drugs, behavioral health beyond an initial allowance, ABA, physical and occupational therapy beyond a visit count, and most inpatient admissions. Medicaid managed care plans often require it for more than commercial plans do. We build the list for your payers.

How long does a prior authorization take?

Payers publish their own turnaround standards for routine and urgent requests, and real turnaround varies by payer and by how complete the request was. A complete request submitted through the payer's preferred channel is the biggest lever you control. We chase anything that passes the payer's own standard.

What if the payer refuses?

We send the refusal reason to your clinician with the options: add documentation and resubmit, request a peer-to-peer review, or appeal. We schedule the peer-to-peer and prepare the file; the clinical conversation is yours.

Can you get an authorization after the service?

Sometimes. Some payers allow retro-authorization within a window, usually for emergencies or when eligibility could not be confirmed. Many do not. We request it where the payer permits and tell you plainly when a balance cannot be recovered.

Do you handle authorizations for NEMT trips and home care hours?

Yes. Trip authorizations through brokers and service authorizations for waiver hours follow different rules from medical authorizations, and we work them under NEMT billing and home care billing.

Who talks to the payer, you or us?

Your biller does the paperwork, portal work and phone follow-up. Your clinician only steps in for a peer-to-peer review or when the payer needs a clinical judgment.

Can prior authorization be outsourced?

Yes. The request, the clinical attachments, the portal and fax submissions, the status checks and the renewal tracking can all be done by a dedicated biller working in your EHR and the payer portals. Since January 1, 2026, Medicare Advantage plans, Medicaid and CHIP programs and their managed care plans must send prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard ones under CMS-0057-F (source 1); Marketplace plans on the federal exchanges are not covered by those timeframes. A request past those limits is worth chasing. The pricing page explains what drives a quote for this work.

Which prior authorization tasks stay with our clinicians?

Medical necessity, the choice of service and the peer-to-peer call. A biller gathers the documentation, submits, chases and records the decision, and tells the clinician when a payer wants a conversation. Nothing clinical is decided outside your practice.