Prerequisites
- Eligibility verified — see Verify eligibility
- A per-payer list of auth-required services
- A field in the PM system where the auth number lives
- Portal access for each payer
Steps
1
Build the auth-required list, per payer
Payers publish these, and they change. Build a reference list of the CPT codes you commonly perform, marked by payer for whether authorization is required.Review it quarterly. Payers add codes to the list without much notice.
2
Trigger the request at scheduling
Not the day before. Authorization turnaround ranges from same-day to several weeks, and a request submitted late means either a rescheduled patient or an unbillable service.
3
Submit through the payer's preferred channel
Include: patient and member ID, diagnosis, the specific CPT codes, the clinical justification, the requesting and rendering providers, the facility, and the anticipated date.
4
Request expedited review where clinically warranted
Payers have expedited pathways where a delay would jeopardize the patient. Use them when genuinely applicable, and know that misusing them erodes their availability.
5
Track it until you have an answer
A tracking log with: patient, service, payer, submission date, expected turnaround, follow-up dates, status, auth number, valid date range, and authorized units.Follow up before the anticipated service date, not after.
6
Capture the number in the PM system's authorization field
This is where the process most often fails. The authorization is obtained, the number is written in the clinical note, and it never reaches the billing field, so it never reaches the 837, and the claim denies CO-197 exactly as if no authorization existed.Put it in the structured field the claim pulls from. Then build a scrubber edit that blocks submission when a CPT on the payer’s auth list has no authorization number. A structural control works on a Friday afternoon; a checklist item depends on a person.
7
Verify the authorization actually matches
Before the service: right CPT codes, right units, right date range, right rendering provider, right facility. An authorization for one procedure code does not cover a different one, and an expired date range denies the same as no authorization.
8
Handle denials with a peer-to-peer review
When authorization is denied, most payers offer a peer-to-peer — your clinician speaks with the payer’s reviewing physician.Prepare: the clinical rationale, relevant guidelines, prior conservative treatment tried, and the specific coverage criterion at issue. Schedule promptly, since the window is limited. A prepared peer-to-peer overturns a meaningful share of authorization denials.
Retro-authorization
Some payers permit authorization after the service in defined circumstances — urgent or emergent care, or where eligibility was in question at the time. Ask; don’t assume. Where available, there is a deadline. Where unavailable, your remaining options are an appeal on medical necessity or a write-off.What you cannot do
Verify it worked
- Per-payer auth-required list built and reviewed quarterly
- Request triggered at scheduling
- Submitted through the payer’s preferred channel, with confirmation retained
- Tracked to an answer
- Auth number in the structured PM field, not only the clinical note
- Scrubber edit blocking submission when an auth is required and missing
- Authorization verified against CPT, units, dates, provider, and facility before the service
- Peer-to-peer process defined and used