Prior authorization is the step that gets skipped when the front desk is short a person, and it is the denial that cannot be appealed on the merits afterward. We obtain, track and renew authorizations before the visit so the claim is payable on the day the service is performed, and we tell you the morning before if it is not.
Which services usually need prior authorization
The list is longer than most schedulers expect and it differs by payer. Advanced imaging, meaning MRI, CT, PET and nuclear studies, almost always needs it for commercial and Medicare Advantage plans. Injections and infusions, particularly biologics and specialty drugs billed under J codes, need it and often need the drug and the administration approved separately. Surgical and in-office procedures, sleep studies, DME above a dollar threshold, and physical therapy beyond an initial visit count are common. Behavioral health sessions are frequently authorized in blocks, and the block runs out quietly. We build a payer-by-payer matrix for your top CPT codes so scheduling knows at booking, not at check-in, whether an auth is required.
How we obtain and track them
Every auth request starts with a check of the payer portal. Where a payer routes imaging through a radiology benefit manager such as eviCore or AIM, we submit there and follow their clinical criteria. Where the portal fails or the case is urgent, we call, and we log the reference number, the representative name and the time. Turnaround expectations are set by payer: routine commercial requests typically return within two to five business days, urgent requests inside 72 hours, and RBM imaging requests often the same day when the clinical notes are attached. Every request sits in a single log with a status, a next action and an owner until it is approved, denied or withdrawn.
The CO-197 and CO-15 denial pattern
CO-197 is the payer saying no authorization was on file. CO-15 is the payer saying the authorization number on the claim is missing or invalid. A CO-15 is often a clerical fix: the auth exists and the number was mistyped, left off, or attached to the wrong line. A CO-197 means the service was performed without approval, and the only path is a retro-authorization request, which most payers allow only within a short window, often 2 to 14 days, and only for specific reasons like emergency or a coverage change the practice could not have known about. We work both within 48 hours of posting because the retro window is the shortest deadline in billing.
Matching what was authorized to what was performed
An authorization is for a specific CPT, a specific number of units, a date range, and often a specific site of service. The claim has to match all four. The most common miss is a procedure that changed in the room: an MRI authorized without contrast performed with contrast, an injection authorized for one level given at two, or a therapy plan authorized for eight visits that ran to ten. Before each claim goes out we compare the billed CPT and units against the authorization on file. If they differ, we hold the claim and request a modification or an added unit before submitting, because a mismatched claim denies and a denied claim on a modified service is hard to recover.
The auth calendar for expiring authorizations
Authorizations expire, and blocks of visits run out, and both happen without a warning from the payer. We keep an auth calendar for every active authorization in your practice showing the end date, the units used against the units approved, and the renewal lead time the payer requires. Fourteen days before an auth expires, or when 75 percent of approved units are used, the renewal request goes out with the updated clinical notes. For behavioral health and therapy, where a patient may be seen weekly for months, this is the difference between continuous coverage and a gap of unpaid sessions that the patient did not know they would owe. Scheduling sees the calendar too, so an appointment is never booked past an expired auth.
What you get
Every morning your front desk receives a daily auth status log listing each pending request, its payer, its reference number, its status and the next step. Alongside it come pre-visit alerts for the next three business days: any scheduled visit where an auth is required and not yet approved is flagged, with a recommendation to hold, reschedule or proceed with an ABN or self-pay conversation. You get a monthly summary of requests submitted, approved, denied and appealed by payer, with turnaround times, so you can see which payers are slow and which CPT codes are being denied on medical necessity.
What Is Included
- Payer portal and phone submissions
- Radiology benefit manager requests
- Authorization calendar with expiry alerts
- Retro-authorization and CO-197 appeals
| CMS prior authorization rules | Federal rules set response deadlines and denial reason requirements for impacted payersSource: CMS, Prior Authorization and Interoperability |
|---|---|
| Denial reason codes | CO-197 and CO-15 are claim adjustment reason codes maintained by X12Source: X12, Claim Adjustment Reason Codes |
Prior Authorization Services: Common Questions
It depends on the payer, but advanced imaging, injections and specialty drugs, most surgical procedures, DME, sleep studies, extended therapy and behavioral health sessions are the usual list. We build a payer-by-CPT matrix for your practice so scheduling knows at booking rather than at check-in.
Routine commercial requests typically return in two to five business days, urgent requests inside 72 hours, and imaging requests through a radiology benefit manager often the same day when clinical notes are attached. Medicare Advantage plans vary widely. We set the expectation per payer and flag anything that goes past it.
Sometimes. Most payers allow a retro request within a short window, often 2 to 14 days, and only for reasons such as an emergency or a coverage change the practice could not have known about. We submit within 48 hours of the denial posting, but we will be honest that routine services performed without an auth are usually not recoverable.
The claim must match the authorized CPT and units, so a changed procedure needs a modified authorization before the claim goes out. We compare each claim against the auth on file, hold any mismatch, and request the modification. Payers are far more willing to amend an auth before the claim than after a denial.
Yes. The auth calendar and pre-visit alerts are built from your schedule, and the authorization number is recorded in your PM system so it flows to the claim automatically. Your front desk sees the same log we do, and nothing lives in a spreadsheet only we can open.
It is a separate service because the work happens before a charge exists and cannot be paid for as a percentage of collections. It is priced per authorization or as a flat monthly fee based on volume. Practices that use us for billing get a reduced rate, and the free billing audit will show you how many CO-197 and CO-15 denials you are currently absorbing.