Prior Authorization: How to Reduce Delays and Denials

Prior authorization (PA) is a payer's approval that must be obtained before certain services, procedures, imaging or medications are provided. If it is missing, the claim will usually be denied – and many payers will not approve it after the fact.

Services that often need prior authorization

• Advanced imaging such as MRI, CT and PET scans
• Elective surgeries and some outpatient procedures
• Specialty and high-cost medications, infusions and injections
• Physical, occupational and speech therapy beyond a set number of visits
• Durable medical equipment and home health services
• Behavioral health levels of care

A reliable authorization process

1. Check requirements for each payer and service when the order is placed.
2. Collect documentation – diagnosis, history, prior treatments and the provider's notes.
3. Submit through the payer portal or ePA system and record the reference number.
4. Follow up until a decision is received; respond quickly to requests for more information.
5. Record the authorization number, approved units and date range in the billing system.
6. Track expiry so services are not provided after the authorization ends.

What is changing

CMS's Interoperability and Prior Authorization Final Rule requires Medicare Advantage, Medicaid, CHIP and certain marketplace plans to send decisions within 72 hours for urgent and 7 calendar days for standard requests, starting in 2026, and to give a specific reason for denials. Electronic prior authorization systems are being phased in after that. Commercial payer rules vary, so each payer's policy still needs to be checked.