Submitting a prior authorization request

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 reliably produces delay, a request for more information, or an administrative denial.

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.

1. 01

   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.
2. 02

   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.
3. 03

   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.
4. 04

   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.
5. 05

   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.

Payers designate how they will accept a request, and submitting through the wrong channel is a common cause of avoidable delay. Most payers publish one or more accepted methods, and the choice among them is constrained by what the payer supports for a given plan and service.

Whatever the channel, a request the payer can adjudicate contains a consistent core of information. Missing or inconsistent elements are the most frequent reason a request is pended 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.

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.

1. 01

   Capture proof of submission

   Save the portal confirmation, fax transmission report, or call reference so the date and time of submission are documented.
2. 02

   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.
3. 03

   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.
4. 04

   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.

Most submission failures trace to a handful of recurring causes, nearly all of which are preventable 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.