Prior authorizations: managing approvals
Submit and track prior authorization requests.
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Prior authorizations (prior auth) are approvals from insurance companies before they'll cover certain medications, procedures, or services. This article covers submitting requests, tracking status, and handling denials.
What needs prior auth?
Common items requiring prior auth: specialty medications, imaging (MRI, CT), procedures (colonoscopy, surgery), DME (wheelchairs, CPAP), and certain lab tests. The need for prior auth is determined by the payer and the specific plan. Your EHR may flag items that typically require auth, but always verify with the payer.
Submitting a request
Go to Billing → Prior auth → New request. Select patient and payer. Choose request type (medication, procedure, service). Fill in clinical details: diagnosis codes (ICD-10), requested service (CPT/HCPCS), quantity, and clinical justification. Attach supporting documents: chart notes, lab results, imaging reports. Click Submit. The request is sent electronically if the payer supports it; otherwise, you'll need to fax or call.
Tracking status
Requests move through statuses: Draft → Submitted → Payer review → Approved/Denied → Expired. Check status under Billing → Prior auth. The list shows request date, payer, patient, service, status, and expiration date. Click a request to see details and all status updates. You'll get notifications when status changes.
When approved
Approved requests show an authorization number and expiration date (typically 30-90 days). Save the auth number — you'll need it on the claim. The auth is linked to the patient and service. When you submit a claim for that service, the system automatically attaches the auth number. If the service changes, you may need a new auth.
Handling denials
If denied, the payer provides a reason: "Not medically necessary", "Incomplete information", "Service not covered". You can appeal by clicking Appeal and providing additional clinical justification. Appeals can be peer-to-peer (you talk to the payer's medical director) or written. Track appeals under the same request — they appear as child records.
Urgent and retro requests
For urgent requests (patient needs service within 72 hours), check "Urgent" when submitting. Payers must respond within 72 hours for urgent requests (vs 15 days for standard). For retro authorizations (service already provided), check "Retro" and explain why auth wasn't obtained beforehand. Retro approvals are harder to get.