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Module 7 · Insurance Verification, Prior Authorization & Patient Access
Lesson 4 of 5

Authorization Submission and Follow-Up

A strong authorization workflow combines payer-rule verification, complete submission, deadline tracking and documented follow-up so unresolved requests are visible before the date of service.

Intermediate20-24 minFree lesson

Practical workflow

Check requirement→Gather data→Submit→Track→Respond→Confirm outcome

Before submission

  • Confirm the request is required for the patient's exact plan and planned service.
  • Use the payer's current portal, transaction or other approved workflow.
  • Include complete clinical and administrative information.
  • Confirm who is responsible for follow-up and the planned service date.

Pending requests

Worklists should show the request date, payer, service date, current status, missing information, next follow-up date and owner. If the payer asks for more information, respond through the required channel and retain submission evidence.

CMS modernization context

The 2024 CMS Interoperability and Prior Authorization Final Rule requires certain impacted payers to improve prior authorization processes. Some operational provisions began in 2026, while major Prior Authorization API requirements generally apply beginning January 1, 2027. These requirements do not replace the need to follow each payer's current production process.

Current-source rule: Prior authorization requirements change. Verify current payer policy, service criteria and submission method for every production request.

Quick knowledge check

What should a pending authorization worklist include?

Status, planned service date, next action, missing information and ownership.

What if the payer asks for more documentation?

Respond through the required workflow and preserve proof of submission.

When do major CMS Prior Authorization API requirements generally begin for impacted payers?

January 1, 2027.

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Training note: This material is for education and staff development. Payer rules, plan benefits, coding guidance, contracts and regulations change; learners should verify current requirements with authoritative payer, CMS and coding resources when performing real billing work.