A patient is in the chair, the visit is booked, and then someone notices the procedure needed approval from the insurer. The appointment moves, the patient is frustrated, and your schedule has a hole in it. Prior authorizations are not going away, but most of the pain comes from finding out too late. A simple, repeatable workflow fixes that.
What a prior authorization is
A prior authorization (sometimes called a pre-authorization or pre-certification) is approval from the patient's health plan before a service is provided. Without it, the plan can deny the claim even when the care was appropriate. Requirements differ by payer, by plan and by service, and they change during the year. That is why memory and good intentions are not enough.
Step 1: Keep a living list of what needs approval
Start a shared list of the services your practice performs that commonly require authorization, broken down by your top payers. Imaging, certain injections, specialty drugs, sleep studies and some procedures are typical examples, but your list should come from your own denials and payer updates, not a generic template.
- Note the payer, the service, and where the request is submitted (portal, phone or fax).
- Record what clinical documentation the payer usually asks for.
- Review the list every quarter, and whenever a payer sends a policy update.
Step 2: Check at scheduling, not at check-in
The best moment to catch an authorization is when the appointment is made. Add one question to your scheduling script: does this visit include anything on the authorization list? If yes, flag the appointment so the request starts that day. Waiting until the day before leaves no time if the payer asks for more records.
Step 3: Submit complete requests the first time
Most delays come from requests that are missing something. Before you submit, confirm the patient's current coverage, the exact procedure and diagnosis codes, the ordering provider, and the notes that support medical necessity. A short checklist taped next to the person who submits requests saves days of back and forth.
An authorization request that is complete on day one is usually decided faster than one that is perfect on day five.
Step 4: Track every open request in one place
Use a simple tracker, even a shared spreadsheet, with the patient, service, payer, date submitted, reference number, status and appointment date. Sort it by appointment date every morning. Anything still pending within a few days of the visit gets a follow-up call. Without a tracker, open requests live in inboxes and sticky notes, and that is where they get lost.
Step 5: Record the approval details on the claim
When approval arrives, save the authorization number, the approved service and codes, the number of visits or units, and the valid dates. Put the number where your biller will see it when the claim is created. A common and frustrating denial happens when the approval existed but the claim did not reference it, or the service fell outside the approved dates.
Step 6: Watch for changes after approval
If the provider changes the planned procedure, adds units, or the visit moves outside the approved window, the authorization may no longer apply. Build a habit: any change to an authorized service goes back to the person who handles authorizations before the visit happens.
When a request is denied
A denial is not always the end. Read the reason carefully. Often the payer wants more documentation, a different code, or a peer to peer conversation with the provider. Note the appeal deadline the day the denial arrives. Keep copies of everything you send.
Who should own it
Authorizations go smoothly when one person, or one small team, owns them from flag to approval. Shared ownership usually means nobody follows up. If your front desk is already stretched by phones and check-ins, authorizations are one of the first tasks worth moving to a dedicated person or an outside team.
A quick weekly checklist
- Every new appointment screened against the authorization list.
- Every request submitted with complete documentation.
- Tracker reviewed every morning by appointment date.
- Approval numbers attached before claims go out.
- Denials logged with reasons, so your list gets smarter over time.
InCareMD helps independent practices with front desk support, insurance verification and billing, including prior authorization follow-up. If authorizations are causing reschedules in your practice, a free practice review is a good place to start.