Prior Authorization Workflow for Medical Practices: A Practical Guide

Prior authorization work becomes difficult when requirements are checked late, documentation is incomplete or status information is scattered across staff inboxes and payer portals. A repeatable workflow helps the practice know what was requested, what was submitted, what is still pending and what the billing team needs before a claim is created.

1. Verify whether authorization is required

Requirements can vary by payer, plan, service, diagnosis, site of care and date. Check the current payer or plan source rather than relying only on an old internal list. Document the source and the date of the verification.

2. Confirm eligibility and benefit context

Authorization is not a substitute for eligibility or benefit verification. Confirm that coverage is active and that the service fits the relevant benefit context before investing time in the request.

3. Collect the required clinical and administrative information

Create a checklist for the service type. Depending on the payer and request, the submission may need diagnosis information, procedure details, provider information, clinical notes, prior treatment history, imaging or other supporting documentation.

4. Submit through the required channel

Payers may use portals, electronic workflows, fax or other methods. Record the submission date, method, confirmation/reference number and the exact service or units requested.

5. Track status and follow-up date

Every pending authorization should have an owner and a next follow-up date. A shared workqueue is more reliable than individual memory. Track pending, approved, denied, additional-information-needed and expired statuses separately.

6. Communicate the decision to scheduling and billing

When approved, capture the authorization number, approved service, units or visits, effective dates and any other restrictions. Make sure the information reaches the team that schedules the service and the team that bills it.

7. Monitor expirations and visit limits

For recurring treatment, one approval may not cover every future visit. Track expiration dates and remaining authorized units so the practice can act before coverage is exhausted.

8. Investigate authorization-related denials

If a claim denies for authorization, compare the payer response with the original request and approval. Check whether the billed service, provider, location, date and units match what was authorized. If the issue is recurring, update the upstream workflow.

What should a prior authorization tracker include?

• Patient and payer identifiers appropriate for the practice’s secure system
• Service/procedure being requested
• Ordering and rendering provider information
• Submission date and channel
• Reference or authorization number
• Status and follow-up date
• Approved dates, units or visits
• Reason for denial or request for additional information
• Handoff note to scheduling and billing

Keep protected health information in approved systems and follow the practice’s privacy and security procedures. A tracker should improve coordination without creating an uncontrolled copy of sensitive data.