Service

Prior authorization management

Auth requirements are expanding and payer turnaround is slowing. We submit, track, and escalate so procedures aren't delayed and claims aren't denied.

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The problem this fixes

Prior authorisation has become one of the heaviest administrative burdens in outpatient care. Requirements vary by payer, plan, and procedure, they change without notice, and a missed auth produces a CO-197 denial that is difficult to overturn after the fact.

For staff, it's phone queues and portal submissions. For patients, it's delayed care. For the practice, it's either unpaid work or cancelled procedures.

What makes it worse than an ordinary denial is that there is usually nobody left to bill. A CO-197 is frequently unappealable, and under many participating provider agreements the balance cannot be transferred to the patient where the loss resulted from the practice failing to obtain authorisation. The service was delivered, the cost was incurred, and the revenue does not exist.

What goes wrong when this is done badly

Four failure modes we see repeatedly, and each one is a process problem rather than an effort problem.

Working from remembered requirements

Authorisation requirements vary by payer, by plan within a payer, and by CPT code, and they change without notice. A requirement confirmed last quarter is not evidence about this one.

Obtaining the auth and losing the number

The approval sits in a fax confirmation or an inbox and never reaches the claim. The service was authorised and the claim still denies, which is the most frustrating version of CO-197 there is.

Submitting without the clinical record

A request sent without the supporting notes gets pended, and a pended request becomes an expired one. Assembling the documentation first is faster than chasing afterwards.

Losing count of authorised units

Courses of treatment continue on their own clinical rhythm; the authorisation does not. Sessions delivered past an exhausted count are usually unpaid and often unbillable to the patient too.

What's included

Every item below is a deliverable, not a capability statement.

Auth requirement determination

By payer, plan, and CPT code.

Request submission

Via payer portal, fax, or phone — whichever the payer requires.

Clinical documentation assembly

Assembled and submitted with the request.

Status tracking

On a fixed follow-up cadence, not ad hoc.

Escalation

When payers exceed their own turnaround standards.

Peer-to-peer review scheduling

Coordinated with the ordering provider.

Denial appeals on authorisation decisions

Including clinical rationale.

Auth number capture

Attached to the claim so it is not lost between systems.

Expiration and unit-count tracking

For ongoing treatment and therapy courses.

Retroactive authorisation requests

Where a payer’s policy permits them.

How it works

1 Determine We check whether the specific plan requires auth for the specific CPT code.
2 Submit Request filed with the clinical documentation the payer expects.
3 Track Followed up on a fixed cadence until a decision arrives.
4 Escalate Escalated when the payer exceeds its own stated turnaround.
5 Attach and monitor Auth number attached to the claim; remaining units tracked to expiry.

How an authorisation fails

Failure	What actually happened	How we prevent it
Requirement not known	The plan required authorisation for this specific CPT code and nobody checked	Requirement determined per payer, plan and code at scheduling
Request pended	Submitted without the clinical documentation the payer expects	Clinical package assembled to the payer's published criteria before submission
Approval never attached	The authorisation exists in a fax confirmation and not on the claim	Auth number captured against the claim at the point of approval
Units exhausted	Treatment continued past the approved count	Remaining units tracked per patient and re-authorised before the last covered visit
Authorisation expired	The procedure was rescheduled past the approval window	Validity dates tracked, and re-requested when a date moves
Denied on clinical grounds	The criteria were not met, or not evidenced	Appeal with the record, and peer-to-peer review scheduled with the ordering provider

Only the last of these is a clinical disagreement. The rest are process failures with process fixes.

What you get back

A live auth status list by patient and procedure
Auth numbers captured against the claim, not held in an inbox
Remaining units and expiry dates reported before they run out
Escalation history you can show a payer

Who this is for

Specialties with heavy auth burden — orthopedics, pain management, behavioral health, radiology
Practices seeing recurring CO-197 denials
Practices cancelling or postponing procedures while auth is pending
Practices running courses of treatment with authorised unit counts

What we measure

The numbers this service actually moves. You see all of them weekly, in your own system, with the benchmark alongside.

Requests submitted before the date of service As a share of all requests. A practice submitting retroactive requests is not managing authorisation; it is apologising for it. This is the metric that tells you which one you are doing.
CO-197 denial volume and value Both matter. CO-197 denials are frequently unappealable and, under many participating provider agreements, cannot be billed to the patient either, so the dollar value is a straight loss.
Turnaround against payer standard Days from submission to decision, measured against each payer's own published standard. It is what makes escalation a fact rather than an argument.
Authorised units remaining by patient For therapy, behavioural health, wound care and any course of treatment. Re-authorisation has to be filed before the last covered visit, not after the denial.

Benchmark ranges are sourced from MGMA and HFMA MAP Keys. MedBil's own figures are published only with a stated measurement window, per specification section 12.7.

Where this matters most

The specialties where this part of the cycle carries the most risk and the most recoverable revenue.

Gastroenterology Screening vs. diagnostic colonoscopy, modifier 33/PT, auth Dermatology Lesion coding by size and site, cosmetic vs. medical, pathology Physical Therapy Timed vs. untimed units, the 8-minute rule, therapy caps, plan of care Urgent Care High volume, S-codes, place of service, self-pay mix OB/GYN Global obstetric package, antepartum/postpartum splits, ultrasound Wound Care Debridement by depth, skin substitutes, HBOT, documentation of measurements

Proof

Start with your own numbers

We measure your denial rate, A/R ageing and net collection rate against industry benchmarks before you commit to anything. You keep the analysis either way.

90 days of claims data, no patient identifiers needed
A written analysis, not a sales deck
No contract, and no obligation to proceed
Client results published with a stated measurement window, once available

Questions about prior authorization services

How long do authorisations take?

It varies by payer and urgency — from same-day to several weeks. We track and escalate against each payer’s stated standard.

What if an authorisation is denied?

We appeal and coordinate peer-to-peer review with the ordering provider.

Can you get retroactive authorisation?

Some payers allow it in defined circumstances. We pursue it where the policy permits.