How does prior authorization work?
- The service is checked against the payer's list to establish whether an authorization is required at all.
- The request is submitted with the ordering note, diagnosis codes, procedure codes and supporting clinical records.
- A reference number and an expected decision date are recorded, and the request is tracked on a live worklist.
- Pending requests are chased on a schedule, because a submitted request that nobody follows up simply sits.
- Approvals are logged with their number, date range and unit limits; denials go to the clinician for a peer review or appeal.
A worked example
An orthopedic practice in Kentucky kept rescheduling MRI appointments because authorizations were not back in time. An assistant built a worklist: every request logged with the submission date, payer reference and decision due date, chased at day three and day six, and escalated to the clinician when a peer-to-peer review was required. Scheduling stopped booking imaging until the authorization number was on the record. Canceled imaging appointments dropped sharply and the practice stopped absorbing unpaid scans.
Where does prior authorization show up in your tools?
Requests go through payer portals or a clearinghouse, with the authorization number, valid dates and unit count stored on the order in athenahealth, eClinicalWorks or Kareo. A simple tracking sheet in Airtable or the practice system is what stops requests from disappearing.
Common mistakes
- Scheduling the service before the authorization number is on the record, then rescheduling the patient.
- Submitting with thin documentation, which produces a pending request and two more weeks of delay.
- Missing the expiry date or the approved unit count, so a later visit in the same course of care goes unpaid.
Why does prior authorization matter?
Prior authorization is the largest source of administrative delay between a clinician's decision and the patient receiving care. For a small practice it is also unpaid work that has to be tracked daily or it stalls. Getting it onto a worklist with owners and chase dates protects both the schedule and the revenue. This is a plain-language summary, not clinical or billing advice.
How does AssistBPO handle prior authorization?
Prior authorization support is delivered by HIPAA-trained staff working under a BAA with minimum-necessary access to the records each request needs. Assistants prepare and submit the paperwork your clinicians approve, track every request to a decision, and escalate denials to your clinical team. They never provide clinical advice or decide medical necessity.