Submitting a prior authorization request
Submitting a prior authorization request is the step in which a provider transmits a completed request — the proposed service, the supporting clinical documentation, and the required identifiers — to the payer through its designated channel so the payer can review it before the service is furnished. It follows gathering the clinical documentation and precedes tracking the request to a decision. How a request is submitted — the form, the channel, and the required contents — is set by each payer and plan and changes over time, so the current payer source is the authority on the specifics.
Updated 7 min read
Reviewed by Anwaar Tayyab
Director of Billing Operations ·
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Key takeaways
- Submission is the transmittal step: it moves a completed request from the practice to the payer for review before the service is furnished.
- Each payer designates the channel — its portal, an electronic 278 transaction, fax, or phone — and the form or template it will accept.
- A submission should mirror verified eligibility, the correct ordering and servicing provider identifiers, and the specific coded service and units.
- Requirements, channels, and turnaround expectations vary by payer, plan, and jurisdiction and change over time.
- Confirming receipt and recording the reference or authorization number connects the submission to later tracking and billing.
What submitting means in the authorization workflow
A prior authorization is a payer's advance determination that a proposed service meets its coverage and medical necessity criteria. Submitting the request is the discrete act of transmitting that request to the payer — it sits inside the larger prior authorization workflow between assembling documentation and following the request to a decision. A well-prepared submission does not by itself guarantee approval, but a poorly routed or incomplete one can produce delay, a request for more information, or an administrative denial.
A note on terminology
Confirming the request is ready before submission
Submission is only as good as the work in front of it. Before a request is transmitted, several conditions should already be confirmed so the payer receives a request it can act on rather than one it must pend for missing information.
Confirm active coverage
Complete eligibility verification for the plan expected to be in effect on the anticipated date of service, and identify any secondary plan through coordination of benefits so the request is sent to the correct payer.Confirm the service requires authorization
Check the payer's current list of services that require prior authorization. That list is payer- and plan-specific and is revised over time, so a service authorized under one plan may not need review under another.Assemble the clinical documentation
Gather the notes, results, and orders that establish medical necessity, as described in gathering clinical documentation. For some drugs and services the payer may also require evidence that step therapy was tried or is clinically inappropriate.Pin down the coded service and units
Identify the specific procedure or service codes, and the number of units, visits, or the date span being requested, using the standard code sets maintained by their respective owners. The request should describe exactly what will later be billed.Identify the ordering and servicing providers
Record the correct provider identifiers, including each NPI, so the authorization is tied to the entity that will render and bill the service.
Choosing the submission channel
Payers designate how they will accept a request, and submitting through a channel the payer does not accept can delay review. Where a payer accepts more than one method, the choice among them is constrained by what the payer supports for a given plan and service.
| Channel | What it is | Typical trade-off |
|---|---|---|
| Payer portal | Web-based submission on the payer's or a vendor's site. | Structured intake and often an immediate reference number; requires an account and manual data entry. |
| Electronic transaction (278) | The standardized X12 278 request and response exchanged system to system. | Supports automation and is central to electronic prior authorization; depends on payer and practice-system support. |
| Fax | Transmitting a request form and attachments by fax. | Historically widely accepted; harder to track and to confirm receipt. |
| Phone | Telephonic intake, frequently used for urgent or expedited requests. | Useful for verbal or time-sensitive review; usually still requires written follow-up. |
Adoption of electronic methods is expanding under federal rulemaking; see electronic prior authorization and the CMS Interoperability and Prior Authorization rule. Available channels vary by payer and change over time.
What a complete submission includes
Whatever the channel, a request the payer can adjudicate contains a consistent core of information. A request with a missing or inconsistent element is one the payer may pend for additional information.
- Patient and subscriber identification — name, date of birth, and member or subscriber ID as shown on the current card.
- Payer and plan — the specific plan and, where relevant, the line of business handling the request.
- Provider identifiers — the ordering and the servicing or rendering providers, with NPIs and any payer-assigned identifiers.
- The requested service — the specific coded procedure or item, the units or visit count, and the requested date or date span.
- Place and setting of service, where the payer requires it.
- Clinical documentation — the records that support medical necessity, plus any payer-required form or criteria worksheet.
- A requesting contact — a name and callback number for the payer's reviewer to reach.
The request should match the future claim
After submitting: confirmation and next steps
Submission is not complete when the request leaves the practice; it is complete when receipt is confirmed and the request is recorded for follow-up.
Capture proof of submission
Save the portal confirmation, fax transmission report, or call reference so the date and time of submission are documented.Record the reference or authorization number
Log the case or reference number the payer assigns at intake. If the request is approved, record the resulting authorization number together with its valid date range and any unit limit. A reference number issued at submission is not the same as an approval.Track the request to a decision
Monitor the request through status tracking, responding promptly to any request for additional information, since the review clock and any expedited timeframe are set by the payer and, for some plans, by regulation.Mind downstream deadlines
An authorization does not remove the claim's timely filing deadline; the service still must be billed within the payer's window after it is rendered.
Standardize the intake record
Common submission problems and how they are avoided
Submission failures tend to trace to a handful of recurring causes, many of which can be caught at intake.
- Routing to the wrong channel or using a superseded form, so the request is never logged by the payer.
- Sending to the wrong payer after a plan change or a missed secondary payer, which correct coordination of benefits would have caught.
- Mismatched or missing provider identifiers, so the payer cannot tie the request to the rendering entity.
- Documentation that does not establish medical necessity, which leads to a denial or a request for more information.
- For medications and some services, missing evidence that step therapy requirements were met or are clinically inappropriate.
- Submitting for a service that did not require authorization, or missing one that did — both waste time and risk downstream denials.
- A coverage lapse on the date of service that eligibility verification would have identified before submission.
Common questions
Is submitting a prior authorization request the same as getting approval?
No. Submission transmits the request to the payer; approval is the payer's decision after it reviews the request. A reference or case number issued at intake confirms that the payer received the request, not that it authorized the service.
Which submission channel should a practice use?
Whichever channel the payer designates for that plan and service. Accepted methods may include a portal, an electronic 278 transaction, fax, or phone, but they vary by payer and change over time, so the payer's current instructions are authoritative.
Does an approved authorization guarantee payment?
No. Authorization addresses medical necessity and coverage rules in advance, but payment still depends on eligibility on the date of service, correct claim submission, timely filing, and other adjudication rules.
How quickly does a payer respond to a request?
Turnaround varies by payer, plan, service, and whether the request is standard or expedited, and some timeframes are set by regulation. There is no single universal deadline, so the payer's current requirements should be checked.
What happens if the billed service differs from what was authorized?
A mismatch between authorized and billed codes, units, or providers can cause an authorization-related denial. Reconciling authorized units to the billed service before the claim goes out helps prevent it.
Key terms in this article
Defined once, on their own pages.
Continue learning
Related steps that surround submission in the authorization process.
Gathering clinical documentation for authorization
How to assemble the records that support the request before it is submitted.
Tracking authorization status and deadlines
What to do after submission to follow a request to a decision.
Electronic prior authorization
How standardized electronic submission is changing the process.
Prior authorization
The full cluster of articles on how advance approval works.
Authoritative sources
- CMS — Prior Authorization and Pre-Claim Review Initiatives: How They Work (opens in a new tab)
Centers for Medicare & Medicaid Services. States that under prior authorization the provider or supplier submits the request and receives the decision before services are rendered, and that the request is submitted with all supporting medical documentation to the Medicare Administrative Contractor, which returns an affirmed or non-affirmed decision.
- 45 CFR 162.1302 — Standards for referral certification and authorization transaction (opens in a new tab)
eCFR. Adopts the ASC X12 278 health care services review request and response as the standard for the electronic authorization transaction, with the retail pharmacy standard adopted separately. The transaction itself — a provider's request for review to obtain authorization, and the plan's response — is defined at 45 CFR 162.1301.
- X12 Transaction Sets (opens in a new tab)
Accredited Standards Committee X12. The standards body's own catalog, which states that X12 defines and maintains the transaction sets and lists the 278 health care services review request and response.
- 42 CFR 422.568 — Standard timeframes and notice requirements for organization determinations (opens in a new tab)
eCFR. An example of a review clock fixed by regulation rather than by the payer: it sets the outer limit within which a Medicare Advantage organization must decide a standard request for an item or service, and the narrow grounds for extending it. Expedited requests run on a separate regulatory clock at 42 CFR 422.572.