Prior Authorization Assistance
Authorization requirements identified, complete requests submitted, and every approval tracked to a documented determination — before the visit, not after the denial.
A missing authorization is the most avoidable denial in healthcare: the care was appropriate, the claim was clean, and the payer still will not pay — because permission was never asked. Elite Bill Care's prior authorization assistance service finds every service that needs approval, submits complete requests, and follows each one to a documented determination before the appointment happens.
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How an authorization moves through our workflow
- Requirement discovery. During eligibility and benefits verification, we identify which planned services need authorization or referral under the patient's specific plan — not a generic list.
- Complete submission. Requests go to the payer or its benefits manager by portal, electronic transaction or fax as required, with diagnosis and procedure codes and the clinical documentation that establishes medical necessity.
- Tracking to determination. Every open request is followed up on a schedule until approved, pended with a specific information request, or denied — nothing sits in "submitted" limbo while the appointment approaches.
- Verification of the approval itself. Approved units, date ranges, codes and rendering provider are checked against the order. An approval that does not match the service is corrected before the visit, not discovered on the remittance.
- Denial handling. Denied requests move to peer-to-peer preparation for the ordering provider, or into the appeal track with the supporting clinical record.
Services that commonly require authorization
- Advanced imaging — MRI, CT and PET studies, often through a separate radiology benefits manager.
- Procedures and surgeries — outpatient and elective procedures across most commercial plans and Medicare Advantage.
- Specialty medications and injections — including buy-and-bill drugs with strict medical-necessity documentation.
- Therapy services — physical therapy and related disciplines beyond initial evaluation or visit thresholds.
- Behavioral health — psychological testing, intensive programs and ongoing mental health treatment under many plans.
- DME and home health — equipment, supplies and home-based services with coverage rules of their own.
Why authorization requests fail
- Submitted without clinical support — the payer cannot approve what the documents do not establish.
- Wrong channel — sent to the health plan when the benefit is carved out to a separate manager.
- Codes that drift — the authorized code and the performed code differ, and the claim denies against the approval.
- Expired validity — the service was rescheduled beyond the approval window and nobody re-checked.
- No follow-up — pended requests quietly die; the denial (CO-197) arrives weeks later on the claim instead.
Connected to the rest of your billing
Authorizations sit between eligibility and the claim: verification discovers the requirement, authorization secures the approval, and claim submission references it. When a payer denies anyway, the documented authorization trail becomes core evidence in appeals. It is one more reason these services run as a single revenue cycle rather than separate errands — see the full picture on our medical billing services page.
Frequently asked questions
Which services usually need prior authorization?
It depends on the plan, but common categories are advanced imaging (MRI, CT, PET), many surgical and outpatient procedures, specialty drugs and injections, durable medical equipment, home health, and ongoing therapy or behavioral-health services beyond an initial allowance. The requirement is discovered during eligibility verification — which is exactly why the two services run together.
What information does a payer need for an authorization request?
Patient and member details, the ordering and rendering providers, diagnosis codes establishing medical necessity, the procedure or service codes requested, the clinical documentation supporting them, and the planned date and place of service. Incomplete clinical support is the most common reason requests pend or deny.
What is a peer-to-peer review?
When a payer's medical reviewer denies or questions a request, the ordering provider can usually discuss the case directly with that reviewer — a peer-to-peer. We prepare the case file and schedule it; the clinical conversation itself is the provider's, and it resolves many denials that paperwork alone does not.
Can an authorization be obtained after the service was already provided?
Sometimes. Some payers allow retroactive authorization within a defined window, others do not. When it is not possible, the denial may still be appealable with documentation of medical necessity — see denial management. The reliable strategy is not needing retro-auth: that is what tracking and follow-up are for.
How do you track authorization status?
Every request is logged with its submission date, payer reference, status and expiry, and followed up until a determination is recorded. Approvals are checked for units, dates and codes matching what was requested — an approval for the wrong code or date range pays like a denial.
Stop losing claims to CO-197
Tell us your specialty and main payers in a free consultation, and we will show you how authorization tracking would run for your schedule.