Prior Authorization Services
Eliminate treatment delays and denials with our expert prior authorization management. We achieve 94.1% approval rates and process requests in just 4.2 days using specialized clinical expertise and advanced automation.
Outstanding Authorization Performance
Our specialized approach consistently outperforms industry benchmarks across all metrics
Our Comprehensive Authorization Process
Six-step systematic approach ensuring fast approvals and seamless patient care
Authorization Identification
Proactive identification of services requiring prior authorization using comprehensive databases and payer requirements.
Real-time eligibility verification, service code analysis, payer policy review, and authorization requirement determination.
Documentation Assembly
Systematic collection and organization of all required clinical documentation, medical records, and supporting materials.
Medical history compilation, diagnostic reports, physician notes, test results, and treatment plan documentation.
Request Submission
Electronic or portal-based submission of authorization requests with complete documentation packages.
Payer portal navigation, electronic form completion, document uploading, and submission confirmation tracking.
Status Monitoring
Continuous tracking of authorization status with proactive follow-up and communication management.
Daily status checks, automated alerts, escalation protocols, and timeline management to prevent delays.
Decision Management
Processing authorization decisions, managing approvals, and handling denials with appropriate appeals.
Approval processing, denial analysis, appeal preparation, peer-to-peer coordination, and resubmission strategies.
Communication & Coordination
Seamless communication between providers, patients, and payers to ensure treatment continuity.
Provider notifications, patient updates, scheduling coordination, and treatment delay prevention.
Authorization Types We Manage
Comprehensive coverage across all authorization categories with specialized expertise
Surgical Procedures
Complex surgical interventions requiring pre-approval for coverage and reimbursement.
Common Services:
Required Documentation:
- •Detailed operative reports
- •Medical necessity documentation
- •Alternative treatment attempts
- •Surgeon qualifications and credentials
Advanced Imaging
High-cost diagnostic imaging studies requiring authorization for appropriate utilization.
Common Services:
Required Documentation:
- •Clinical indication documentation
- •Previous imaging results
- •Treatment response history
- •Physician clinical notes
Specialty Medications
High-cost pharmaceuticals and biologics requiring prior authorization for coverage.
Common Services:
Required Documentation:
- •Diagnosis confirmation
- •Previous medication trials
- •Laboratory test results
- •Specialist consultation notes
Durable Medical Equipment
Medical equipment and devices requiring authorization for rental or purchase coverage.
Common Services:
Required Documentation:
- •Physician prescription
- •Medical necessity justification
- •Sleep study results (for CPAP)
- •Functional assessment reports
Therapy Services
Rehabilitation and therapy services requiring authorization for extended treatment.
Common Services:
Required Documentation:
- •Treatment plan documentation
- •Functional assessment scores
- •Progress notes and outcomes
- •Physician referral orders
Payer-Specific Authorization Expertise
Deep knowledge of payer requirements and processes for optimal approval rates
Medicare Advantage
Special Requirements:
- •Medicare coverage guidelines compliance
- •Local coverage determination (LCD) adherence
- •National coverage determination (NCD) review
- •Star rating impact consideration
Our Strategies:
- ✓LCD/NCD database integration
- ✓Medicare-specific documentation
- ✓Star rating optimization
- ✓Appeal process expertise
Commercial Insurance
Special Requirements:
- •Plan-specific medical policies
- •Formulary and preferred provider networks
- •Step therapy protocol compliance
- •Cost-effectiveness documentation
Our Strategies:
- ✓Medical policy tracking
- ✓Formulary management
- ✓Network optimization
- ✓Comparative effectiveness research
Medicaid Managed Care
Special Requirements:
- •State-specific guidelines
- •Managed care organization policies
- •Social determinant considerations
- •Prior authorization exemptions
Our Strategies:
- ✓State regulation expertise
- ✓MCO relationship management
- ✓Social service coordination
- ✓Exemption identification
Workers' Compensation
Special Requirements:
- •Work-relatedness documentation
- •Causation analysis reports
- •Return-to-work planning
- •Independent medical examinations
Our Strategies:
- ✓Occupational medicine expertise
- ✓Causation documentation
- ✓IME coordination
- ✓Return-to-work facilitation
Advanced Authorization Technology
AI-powered automation and intelligent workflows optimize every step of the authorization process
AI-Powered Requirement Detection
Machine learning algorithms analyze procedure codes and patient data to predict authorization requirements.
Capabilities:
- Real-time authorization flagging
- Payer policy analysis
- Code-specific requirement mapping
- Historical pattern recognition
Automated Documentation Assembly
Intelligent document collection and organization system streamlines the authorization process.
Capabilities:
- EHR integration and data extraction
- Document template automation
- Missing information identification
- Quality assurance checking
Multi-Payer Portal Integration
Seamless integration with major payer portals for efficient submission and tracking.
Capabilities:
- Single sign-on portal access
- Automated form completion
- Bulk submission processing
- Status synchronization
Real-Time Status Dashboard
Comprehensive tracking and reporting platform for authorization management.
Capabilities:
- Live status monitoring
- Automated alert systems
- Performance analytics
- Predictive timeline forecasting
Specialty-Specific Authorization Excellence
Dedicated experts for complex specialties ensure optimal outcomes
Cardiology
Common Services:
Challenges:
- •Complex procedure coding
- •Multi-vessel intervention approval
- •Device medical necessity
- •Emergency vs. elective distinction
Solutions:
- ✓Cardiology-trained specialists
- ✓Real-time clinical support
- ✓Device database integration
- ✓Emergency authorization protocols
Orthopedics
Common Services:
Challenges:
- •Surgical complexity justification
- •Conservative treatment documentation
- •Implant cost considerations
- •Revision surgery approval
Solutions:
- ✓Orthopedic surgery specialists
- ✓Treatment progression tracking
- ✓Implant cost optimization
- ✓Revision protocol expertise
Oncology
Common Services:
Challenges:
- •Rapidly evolving treatment protocols
- •High-cost medication approvals
- •Clinical trial coordination
- •Compassionate use requests
Solutions:
- ✓Oncology authorization experts
- ✓Treatment protocol databases
- ✓Clinical trial navigation
- ✓Expedited review processes
Mental Health
Common Services:
Challenges:
- •Medical necessity documentation
- •Treatment duration justification
- •Alternative therapy evidence
- •Crisis intervention approvals
Solutions:
- ✓Mental health specialists
- ✓Outcome measurement tools
- ✓Evidence-based protocols
- ✓Crisis response procedures
Authorization Success Stories
Real transformations achieved through our specialized authorization management
Large Cardiology Practice Transformation
Challenge
Cardiology practice with 12 physicians experiencing 40% authorization denial rate and 3-week processing delays affecting patient care.
Solution
Implemented specialized cardiology authorization team with real-time clinical support and automated documentation assembly.
Results
- ✓Authorization success rate increased from 60% to 95.2%
- ✓Processing time reduced from 3 weeks to 3.8 days
- ✓Patient treatment delays eliminated
- ✓Revenue cycle improved by $2.3M annually
- ✓Staff workload reduced by 65%
"The transformation has been incredible. Our patients get the care they need when they need it, and our staff can focus on clinical care instead of authorization paperwork."
Multi-Specialty Surgery Center Optimization
Challenge
Surgery center struggling with complex orthopedic and neurosurgery authorizations, resulting in case cancellations and revenue loss.
Solution
Deployed specialty-specific authorization workflows with AI-powered requirement detection and automated payer portal integration.
Results
- ✓Case cancellation rate reduced by 89%
- ✓Authorization approval rate improved to 93.7%
- ✓Same-day authorization processing achieved
- ✓Monthly revenue increased by $890,000
- ✓Surgery scheduling efficiency improved by 78%
"We went from constantly fighting authorizations to having a smooth, predictable process. Our OR utilization is at an all-time high."
Oncology Practice Authorization Excellence
Challenge
Cancer treatment center facing delays in high-cost medication approvals, impacting treatment timelines and patient outcomes.
Solution
Established oncology-specific authorization protocols with expedited review processes and clinical trial coordination.
Results
- ✓Medication approval time reduced from 12 days to 3.2 days
- ✓Treatment delay incidents decreased by 94%
- ✓Prior authorization success rate reached 92.4%
- ✓Patient satisfaction scores improved to 98.1%
- ✓Clinical staff satisfaction increased by 85%
"Every day matters in cancer care. This system ensures our patients get their treatments on schedule without the stress of authorization battles."
Frequently Asked Questions
Get answers to common questions about our prior authorization services
How quickly can you process prior authorization requests?
Our average processing time is 4.2 days from submission to decision, compared to the industry average of 8.5 days. For urgent cases, we offer expedited processing with same-day submission and 24-48 hour follow-up. Emergency authorizations can often be processed within hours using our direct payer relationships and clinical advocacy.
What happens if a prior authorization is denied?
We have a systematic appeal process with an 89.7% success rate. Our team immediately analyzes denial reasons, gathers additional clinical documentation, and prepares comprehensive appeals. We coordinate peer-to-peer reviews when needed and escalate to medical directors when appropriate. Most appeals are resolved within 5-10 business days.
Do you handle authorizations for all medical specialties?
Yes, we manage prior authorizations across all medical specialties with dedicated experts for complex areas like cardiology, orthopedics, oncology, and mental health. Our team includes clinically-trained specialists who understand the nuances of each medical field and can effectively communicate with payer medical directors.
How do you ensure we don't miss authorization requirements?
Our AI-powered system analyzes every procedure code against comprehensive payer databases to identify authorization requirements in real-time. We maintain up-to-date payer policies and have automated alerts that flag services requiring authorization at the point of scheduling, ensuring nothing falls through the cracks.
Can you integrate with our existing practice management system?
Yes, we integrate seamlessly with all major EHR and practice management systems including Epic, Cerner, athenahealth, NextGen, and many others. Our integration typically takes 1-2 weeks and allows for automatic data extraction, real-time status updates, and comprehensive reporting within your existing workflow.
What documentation do you need to process authorizations?
Documentation requirements vary by service and payer, but typically include physician orders, clinical notes, diagnostic reports, treatment plans, and relevant medical history. Our system automatically identifies required documentation and alerts you to any missing items, ensuring complete submissions every time.
How do you handle urgent or emergency authorizations?
We have dedicated protocols for urgent and emergency cases with 24/7 coverage for critical situations. Emergency authorizations are processed immediately with direct payer contact, while urgent cases receive same-day attention. We maintain emergency contact numbers for all major payers to expedite critical approvals.
What reporting and tracking capabilities do you provide?
Our comprehensive dashboard provides real-time authorization tracking, approval rate analytics, processing time metrics, and denial trend analysis. You can monitor individual case status, identify bottlenecks, track performance by payer and service type, and generate custom reports for operational optimization.
Ready to Eliminate Authorization Delays?
Join healthcare providers who have improved their authorization success rates to 94.1% and reduced processing time to just 4.2 days with our expert services.
✓ No implementation fees ✓ 24/7 urgent coverage ✓ Guaranteed improvement