Prior authorization services
Approvals in place before the visit, and on record for the claim.
We check which services need approval, send each payer a complete request, follow it to a decision and record the authorization number, dates and approved units where your billers will see them. Denials go to a peer-to-peer or an appeal.
- MA & Medicaid decisions
- 72 hrs urgent, 7 days standard
- Every request
- Tracked to a decision
- On record
- Auth number, dates and units
- Price
- Included in full service
Why practices outsource prior authorization
Prior authorization is a staffing problem before it is a payer problem. In the 2025 AMA prior authorization physician survey of 1,000 physicians, practices completed an average of 40 prior authorizations per physician each week, physicians and their staff spent 13 hours a week on them, and 40% of physicians had staff who work exclusively on prior authorization.
Patients wait too: 95% of those physicians said it delays access to necessary care, and 62% of those requesting approval for medical services find it hard to tell whether one is needed.
The check starts with the right plan, so we work from the coverage confirmed by your eligibility and benefits verification, not from last year’s insurance card.
The federal prior authorization rules that started in 2026
The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) covers Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities and qualified health plan issuers on the federally facilitated exchanges. Its operational rules generally took effect on January 1, 2026:
- Decisions within 72 hours for expedited (urgent) requests and 7 calendar days for standard ones, from every payer listed except the exchange plans
- A specific reason for every denial, however the request was sent
- A yearly public report of which services need approval, approval and denial rates and decision times, first due March 31, 2026
- By January 1, 2027, a Prior Authorization API showing which services need approval and what documentation each needs
CMS adds that the decision clock starts when the payer receives the request and runs in calendar time, by portal, fax, phone or API alike. Drugs are outside these rules; employer and other commercial plans not listed set their own timeframes within state and federal law.
Medicare Advantage, Medicaid and traditional Medicare
Medicare Advantage and Medicaid managed care plans each keep their own approval lists. In the AMA survey, 69% of physicians rated the burden high or extremely high for Medicare Advantage, the most of any line of business, against 47% for traditional Medicare.
Traditional Medicare requires prior authorization only for specific services, listed on its prior authorization and pre-claim review page:
- Certain hospital outpatient services: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, vein ablation, implanted spinal neurostimulators, cervical fusion with disc removal and facet joint interventions
- The first five of those in ambulatory surgical centers in ten states, under a demonstration that began in early 2026
- Certain durable medical equipment, prosthetics, orthotics and supplies, and repetitive, scheduled non-emergent ambulance transport
- Since January 1, 2026, the WISeR model in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington, for services such as skin and tissue substitutes, electrical nerve stimulator implants and knee arthroscopy for knee osteoarthritis
For Medicare Advantage patients, the plan’s own list applies instead.
Gold carding: exemptions for a strong approval record
Texas exempts physicians and providers with a high approval rate from prior authorization for a given service. As the Texas Department of Insurance explains, you qualify for a service after submitting at least five eligible requests for it in the evaluation period with at least 90% approved. Since September 1, 2025, insurers must evaluate at least once a year.
It covers state-regulated HMO, PPO and EPO plans, not self-funded employer plans, Medicaid, CHIP or Medicare Advantage. Only 5% of physicians in the AMA survey contract with plans offering such an exemption. Our log records each decision by payer and service, so you can see where you stand.
What a complete request contains
Most delays start with a request the payer sends back. Ours include:
- Current plan and member ID
- Ordering and rendering NPIs
- CPT or HCPCS codes and units
- ICD-10 codes that match the notes
- Site of service and planned date
- Recent notes, imaging and test results
- Treatments already tried
- The payer’s form or criteria checklist
How we run your prior authorizations
Check the requirement
We confirm by payer, plan, code and site of service whether approval is needed and what the payer wants to see.
Build and submit
We build the request from the chart, submit it by portal, fax or phone, and log when the payer received it.
Track and follow up
Open requests are checked against the payer’s timeframe and chased by phone when late or pended for records.
Escalate
Denials and stalled requests go to your provider with a summary, then to a peer-to-peer or a written appeal.
Record the approval
Authorization number, approved codes, units or visits, and dates go where billers and schedulers see them.
Watch expirations and counts
Approvals nearing their end date or visit limit are flagged in time to request an extension.
What we record for every authorization
One shared log, so the approval and the claim match.
- Authorization numberExactly as the payer issued it, ready for the claim.
- Approved codes and unitsWhat the payer approved, which can differ from what was asked for.
- Valid datesStart and end dates, checked against the date of service.
- Payer referenceCall reference numbers and portal or fax confirmations.
- Visits usedA running count against the approved total.
When an authorization is denied
Start with the reason, which payers covered by CMS-0057-F must now state. Missing records or codes that do not match the notes mean a corrected resubmission, and our certified medical coders check every request’s codes against the chart before it goes out.
When the reviewer disputes medical necessity and the plan offers a peer-to-peer review, we book it and brief your provider on one page: the denial reason, the plan’s criteria and the chart evidence that meets them. Preparation matters: only 16% of physicians in peer-to-peer reviews told the AMA the plan’s reviewer often or always had the appropriate qualifications.
Only 21% of physicians always appeal, and 52% cite a lack of staff or time as a reason not to. We draft the appeal for your provider to sign. In Medicare Advantage, a treating physician can request reconsideration for the patient, after telling them, within 60 calendar days of receiving the notice, and the plan must decide a standard pre-service request within 30 calendar days, or 72 hours if expedited.
Claims already denied for a missing authorization go to our denial management team.
What your practice gets
- A requirement check for every scheduled service
- Complete requests built from each payer’s criteria
- A shared log of status, numbers, dates and units
- Alerts before an approval expires or runs out of visits
- Peer-to-peer briefs and appeal letters for denials
- Approvals that match the claims your billers send
Hand us the prior authorization queue. Book a free review of your payers, services and volume, and we’ll quote the work in writing.
Prior authorization questions
Something else? Call +1 786-788-7313 and ask for the authorization team.
All questionsIf we run your full revenue cycle, prior authorizations are included in our full-service rate of 3% to 6% of monthly collections. On their own, we quote them after a free review of your request volume, payers and services, because ten requests a week and a hundred need different setups. The quote is in writing before any work starts.
Under CMS-0057-F, Medicare Advantage plans and Medicaid and CHIP programs, including their managed care plans, must decide within 72 hours for expedited requests and 7 calendar days for standard ones, with extensions of up to 14 days in some cases. Exchange, employer and other commercial plans follow other federal rules, their contracts and state law.
Only for specific services: certain hospital outpatient procedures such as blepharoplasty, vein ablation and facet joint interventions, some of the same procedures in ambulatory surgical centers in ten states, and certain equipment and ambulance transports. Since January 2026, the WISeR model adds selected services in six states. Medicare Advantage plans keep their own lists.
We read the specific reason the payer gave. Missing information is corrected and resubmitted. A medical necessity denial gets a peer-to-peer call, if the plan offers one, or a written appeal with the records and the payer’s criteria. In Medicare Advantage, a treating physician has 60 days from receiving the notice to request reconsideration.
No. Eligibility verification confirms coverage, copay, deductible and plan rules for the date of service. Prior authorization asks the payer to approve a specific service in advance. We confirm coverage first, because a request sent to the wrong plan is wasted, then check whether that plan needs approval for the code and site of service.
A signed business associate agreement, a named login to your EHR or practice management system, access to your payer portals, your schedule as far ahead as you book, and a contact for clinical questions. Your providers stay responsible for the clinical content and take any peer-to-peer call.
Yes. We don’t list our clients on this site, but ask us and we’ll arrange it: with a current client’s permission, we share their contact details so you can hear how we work from them directly.
Specialties we work with
Hand your prior authorizations to us.
Tell us your payers, services and weekly volume. We’ll map the work and quote it after a free review.