Prior authorization services
Prior authorization without a process means slower approvals, more denials, and lost revenue.
Delayed authorizations stall your cash flow, frustrate your patients, and drain your staff’s capacity, all leading up to a slowed-down schedule. MedHeave manages the entire prior authorization cycle from submission to approval, following up with payers relentlessly so your revenue is never stuck in limbo.
Our stats
These aren't aspirational targets. These are what we deliver, consistently, across all practices we work with.
70-85%
Appeal Approval Rate
2-5 days
Standard Turnaround
24-72 hrs
Follow-up Window
After Submission
5-10 days
Average Appeal Resolution Time
You don’t always lose revenue at billing. You can lose it during prior authorization too.
Most prior authorization failures are caused by process gaps, such as missing documentation, incorrect codes, expiring authorizations, and payer requirements that nobody on your team had time to track. Each one alone is manageable. Together, they erode your approval rate, delay your schedule, and hold up claims that should have moved weeks ago.
MedHeave closes all the gaps by managing prior authorization holistically as an end-to-end process. Every request is handled by a dedicated prior authorization specialist who tracks it until approved. Every submission is followed up within 72 hours, and every denial is reviewed before the appeal window closes. We ensure your practice never loses revenue to process failures that had nothing to do with your clinical work.
Gaps in prior authorization
Your staff cannot manage prior authorization along with everything else they are already doing they shouldn’t have to.
A front desk coordinator handling patient intake, phones, and scheduling does not have the bandwidth to track fifteen open authorization requests across six different payer portals, follow up on submissions within 72 hours, and catch an authorization that is expiring in three days. Something always gets missed. And what gets missed becomes a delayed procedure, a held claim, or a denial that lands on your billing team with no clear path forward.
You stop following up after submission
Submitting the authorization request is just the beginning. If nobody on your team is following up within 72 hours, checking payer portals daily, escalating requests nearing the procedure date, and keeping every authorization moving toward a decision, you are leaving your schedule at the mercy of a payer that has no urgency to respond.
You are not tracking expiration dates
An authorization approved today is not valid forever. If a procedure is rescheduled, a treatment plan changes, or a recurring service exceeds its approved visit limit, that authorization may no longer be valid. Most practices discover this after the claim is denied. By then, retro authorization is not always an option, and the revenue is already at risk.
You treat appealable denials as final verdicts
Most authorization denials stem from admin errors like missing documentation, formatting issues, or codes that no longer meet the payer’s requirements. Many can be appealed, while medical necessity denials may be reversed through a peer-to-peer review. But if your team cannot gather documentation and misses the appeal window, recoverable revenue is written off.
Calculate your revenue loss
Do you know how much denied and unappealed authorizations are costing you every month?
Every authorization that gets denied and never appealed is revenue your practice has already earned but will never collect. Use the calculator below to see exactly what that number looks like for your practice.
Fill in your details and click Calculate now to see your estimate.
Our prior authorization services
We do not manage parts of your prior authorization. We manage the entire process.
Whether it is a surgical procedure, a specialty medication, a cardiology outpatient procedure, or a therapy service, MedHeave manages the entire authorization process so every step has a dedicated owner, accountable for the outcome.
Authorization requirement verification
We check payer guidelines, portals, and eligibility responses before any request is submitted to confirm whether a service requires prior authorization. Every submission is necessary, accurate, and aligned with what the payer actually requires before the process moves forward.
Clinical documentation collection
We gather patient demographics, insurance details, CPT and ICD codes, provider information, and supporting clinical notes through direct EMR access or direct coordination with your staff. Every submission goes out with complete documentation, so the payer has no grounds to delay or deny on the basis of missing information.
Multi-channel payer submission
We submit through portals, fax, phone, and clearinghouses based on what each individual payer requires. Every request is logged in a centralized tracking system, so every request is logged, nothing is duplicated, and nothing falls through because of a portal outage or an unreachable phone queue.
Real-time authorization tracking
We track every open authorization request in a centralized system with real-time status updates across all payers simultaneously. You have full visibility into what is pending, what is approved, and what needs immediate follow-up without waiting on a status update from anyone. Call reference numbers are saved for future reference and appeals.
Urgent and emergency authorization handling
When a procedure is scheduled within 24 to 48 hours, we mark it urgent, submit immediately, and follow up aggressively until a determination is received. For emergency situations, we follow payer-specific emergency protocols and submit retro requests where the payer allows it, so the claim has the best possible path to payment.
Authorization renewal and visit limit monitoring
We track approved visit limits and expiration dates across every active patient and alert your practice before limits are reached or authorizations are due to expire. For recurring treatments like infusions, physical therapy, and behavioral health, we initiate renewals proactively so an expired auth never interrupts an ongoing treatment plan or holds up a claim mid-cycle.
Denial management and appeals
Every adverse determination is reviewed within 72 hours. We identify the exact reason for denial, whether clinical, administrative, or documentation-related, and build the appeal with the correct supporting documentation before the window closes. Our appeal approval rate varies between 70 to 85 percent, and no denial is written off without exhausting every available appeal option first. When a denial is based on medical necessity, it includes requesting a peer-to-peer review with the payer’s physician.
Retro authorization management
When a service is rendered without a completed authorization, we assess retro authorization eligibility immediately and submit it where the payer allows it. We do not write off a claim until every available path to a valid authorization has been exhausted.
Mid-treatment insurance change management
When a patient changes insurance mid-treatment, we reverify benefits under the new plan and obtain updated authorizations before the next service date. Every claim that goes out after an insurance change goes out under verified, active coverage, so treatment continues without interruption, and no revenue is put at risk by a coverage change nobody tracked.
Pre-billing authorization verification
We verify the auth status, date of service (DOS), and authorized units against the claim before submission. Expired auths, DOS outside the authorized range, and exceeded units are flagged and resolved before the claim reaches the payer.
Our specialties
Whatever your specialty bills, we already know what the payer needs to authorize them.
Authorization requirements shift with every specialty, every payer, every plan type, every sub-plan, and every service type. We manage them across multiple specialties with teams that already know what each payer expects to see before a request goes out.
Behavioral health
In behavioral health, missing eligibility or session tracking can cost several visits, not just one. We stay ahead of authorization limits, benefit caps, telehealth rules, and co-pay terms so billing stays steady through care.
Podiatry
For podiatry billing, we make sure modifiers like 25 and RT/LT are accurate, services align with global periods and payer edits, and orthotics always meet payer-specific authorization and DME requirements before claims go out.
Urgent care
We handle urgent care billing across walk-ins, diagnostics, and procedures. From there, we track payor coding rules, facility contracts, prior authorizations, and eligibility checks so claims never get delayed, cut, or denied.
Orthopedic
We handle orthopedic billing, making sure procedures get authorized upfront and modifiers like LT/RT and bilateral get applied well. Surgical cases with implants are coded and billed the way payers actually expect for payment.
Cardiology
Cardiology billing often triggers NCCI edit denials, bundling issues, and global period violations when E/M services and procedures are billed together. We manage coding and modifier logic to reduce denials and boost payments.
DME
DME billing is handled by aligning orders, documentation, and delivery timelines with payer rules. We apply HCPCS coding, manage capped rentals, and enforce refill limits so claims are never denied for missing paperwork today.
Pediatrics
In pediatrics, we handle well visits and immunizations, making sure vaccine administration and VFC eligibility are correct. Age-based coding stays accurate as well, so nothing gets missed, underbilled, or delayed at any visit.
Anesthesia
The accuracy of anesthesia billing depends on capturing start and stop times correctly. We ensure precise time capture, apply base units and modifiers, and handle medical direction & concurrency so each unit is billed right.
Don’t see your specialty? We likely work in it.
Our process
From the first authorization request to the final approval, here is what our process looks like.
Every step in our process has a single purpose: making sure nothing in your authorization cycle is left unowned, untracked, or unresolved.
Request review
Incomplete or inaccurate authorization requests are often delayed, returned, or denied by the payer. In such cases, the reasons have nothing to do with medical necessity and it’s all because of the information submitted to the payer. When we receive an authorization request, we review the service details, provider information, patient data, and CPT and ICD codes before anything is submitted to the payer. If any detail is incorrect or missing, we identify and resolve it at this stage.
Verification of benefits
Submitting to the wrong payer, under an inactive plan, or for a service the plan does not cover guarantees a denial that verification would have prevented. We confirm the patient's active coverage, verify the plan is active on the date of service, establish what the plan covers for the specific service being requested, and determine whether that service requires prior authorization under that plan before any request is submitted. We also identify any coverage limitations, exclusions, or coordination of benefits requirements that apply to that patient and that plan.
Auth requirement confirmation
We check payer-specific guidelines, portals, and eligibility responses to confirm whether the service, under the specific CPT codes and patient plan involved, actually requires prior authorization before anything is submitted. If authorization is not required, we document that confirmation so the billing team has it when the claim goes out. If it is required, the request moves forward immediately.
Collecting clinical documentation
We gather patient demographics, insurance details, CPT and ICD codes, provider information, clinical notes, and any additional documentation the payer requires for that specific service type. We collect this through direct EMR access or in direct coordination with your practice team. A missing progress note, a referral, or a medical necessity letter can delay or deny an authorization before it ever reaches clinical review. Every request we submit goes out with complete, payer-aligned documentation, so none of those gaps exist.
Submission to payer
Every payer has a preferred submission channel for every service type. We know which one applies and submit accordingly, whether that is a portal, fax, phone, or clearinghouse. Every submission is logged with a timestamp, submission method, and confirmation of receipt. If a portal is down or a phone queue is unreachable, we immediately switch to an alternative submission method while documenting every attempt, so there is a complete audit trail from the first submission through final confirmation.
Status tracking
Every open authorization request is tracked in real time across all payers simultaneously through a centralized system with live status updates, follow-up deadlines, and expiration date alerts. We do not rely on payers to notify us when they have made a decision on a request. We actively monitor every open request so that approvals, denials, and payer requests for additional information are identified and acted on the same day, not discovered days later when a procedure is already on the schedule and a determination still has not come through.
Follow up
If no determination is received within 24 to 72 hours of submission, we contact the payer directly and continue following up until a determination is received. For urgent requests where a procedure is scheduled within 24 to 48 hours, we follow up from the moment of submission, escalate through every available payer contact, and do not stop until the authorization is confirmed or denied.
Timely updates
Once an authorization is approved, we log the approval with its expiration date, approved service details, authorized CPT codes, and any unit or visit limits attached to it, and update your practice immediately. Your scheduling team knows the procedure is cleared, and we have the authorization number, approved codes, and expiration date confirmed before the claim is submitted. If an authorization is only partially approved or includes conditions or restrictions, we make sure you understand exactly what was authorized, what was not, and what action is required next.
Why MedHeave
We don't passively wait for approvals. We actively drive every authorization request to a confirmed outcome.
At MedHeave, every authorization request is actively managed, not simply submitted. Every case has a defined owner who tracks its progress, responds to payer requirements, follows up on outstanding requests, and keeps it moving until approval is confirmed.
We follow up without being asked
Every open authorization request that has not received a determination within 24 to 72 hours of submission gets a direct follow-up with the payer. We do not wait to be reminded, we do not batch follow-ups, and we do not let a request sit in a payer queue while your procedure date gets closer.
We submit the way each payer requires
We submit through portals, fax, phone, and clearinghouses based on what each individual payer requires for that specific service type. Every submission is logged with a timestamp and confirmation of receipt. If a portal goes down or a phone queue is unreachable, we switch methods immediately and document every attempt.
We appeal every denial before anything is written off
Every denied authorization is reviewed within 72 hours. We identify the exact reason for denial, whether clinical, administrative, or documentation-related, and build the appeal with the correct supporting documentation before the window closes. With a 70 to 85 percent appeal approval rate, no denial leaves our process without every available option being exhausted first.
Nothing expires without your practice knowing first
We track authorization expiration dates, approved unit limits, and visit thresholds across every active patient. Your practice is alerted before a limit is reached or an authorization is due to expire, so that a recurring treatment or a rescheduled procedure is never left without valid coverage.
Retro authorization is handled before a claim is put at risk
When a service is rendered without a completed authorization, we assess retro authorization eligibility immediately and submit it where the payer allows it. If retro authorization is not available, your practice knows before the claim is submitted, so you can determine whether to absorb the cost or collect from the patient directly.
Keeping your practice informed at every stage
You always know whether your authorization request is pending, approved, denied, or under appeal. Running after us for updates, waiting on status calls, or dealing with surprises after a denial has already affected your schedule is least likely to happen.
When prior auth services go wrong
When prior auth is not managed right, the consequences are not limited to the authorization process.
The damage because of unmanaged prior authorization does not stay limited to the auth process. It surfaces in your schedule when a procedure has no confirmed coverage, in your claims when a denial comes back that should never have happened, and in your collections when revenue that was clinically justified never gets paid.
A procedure gets scheduled without a confirmed authorization
Your scheduling team books the appointment, assuming the authorization is in progress. The date arrives, the authorization has not been confirmed, and the procedure either gets delayed or goes ahead without coverage. If it goes ahead, you are now dependent on retro authorization, which not every payer allows, and the claim is at risk from the moment the service is rendered.
A claim goes out under an expired authorization
An authorization that was valid at the time of scheduling may have expired by the time the service is rendered or the claim is submitted. If nobody caught the expiration date, the claim goes out under an authorization the payer no longer recognizes as valid. The denial that comes back is not correctable with a simple resubmission. It requires either a retro authorization request or an appeal, both of which take time your revenue cycle does not have to spare.
A denial sits past its appeal window
Every payer has a window within which an adverse determination can be appealed or a peer-to-peer review can be requested. Once that window closes, the denial is final, and the revenue attached to it is gone. When denials are reviewed weekly or monthly instead of within 72 hours, a portion of those denials will already be past their appeal window by the time anyone looks at them. That is not a billing problem. It is a process problem that started the moment the denial was not acted on immediately.
A retro authorization request gets rejected
When a service is rendered without a completed authorization, and the payer does not allow retro authorization for that service type, the claim has no path to payment. The service was rendered, the provider did the work, and without the authorization in place before the date of service, the cost either goes unrecovered or falls on the patient as an out-of-pocket expense. This is the most avoidable outcome in the entire authorization process and the one that can cost your practice the most.
FAQs
Questions providers like you ask us about prior authorization services.
If you are managing prior authorization services in-house or evaluating whether to outsource it, these are the questions worth having answered first.
How long does prior authorization take?
As part of our services, prior authorization standard requests typically take 2 to 5 business days, depending on the payer and service type. Commercial payers tend to respond faster. Medicare Advantage and Medicaid plans often take longer due to stricter documentation requirements and more complex review processes. Urgent requests, where a procedure is scheduled within 24 to 48 hours, require immediate submission and aggressive follow-up to get a determination within that window.
What are the most common reasons prior authorization gets denied?
The most common reasons are missing or incomplete clinical documentation, incorrect CPT or ICD codes, lack of demonstrated medical necessity, and services that do not meet the payer’s current coverage criteria. Most of these denials are administrative, not clinical, which means they are preventable at the submission stage and appealable when they do occur.
Can a prior authorization denial be appealed?
Yes. Every denied authorization should be reviewed for appeal eligibility before it is written off. Most administrative denials, those resulting from missing documentation, incorrect codes, or formatting issues, are winnable on appeal when the right documentation is submitted within the payer’s appeal window. MedHeave’s appeal approval rate sits between 70 and 85 percent.
What happens if a prior authorization expires before the service is rendered?
If an authorization expires before the procedure takes place, the claim will be denied when submitted. At that point, the options are a retro authorization request, which not every payer allows, or an appeal. The most effective way to avoid this is active tracking of every authorization’s expiration date so renewals are initiated before the window closes, not after the claim is already denied.
What is retro authorization, and when does it apply?
Retro authorization is a request submitted after a service has already been rendered without a prior authorization in place. Some payers allow it under specific circumstances, such as emergency situations or cases where the authorization process was initiated but not completed before the date of service. It is not universally available, and approval is not guaranteed. It should be treated as a last resort, not a fallback process.
Do all payers require prior authorization for the same services?
No. Prior authorization requirements vary significantly by payer, plan type, and service category. What requires authorization under a commercial plan may not require it under Medicare fee-for-service, and what a Medicare Advantage plan requires can differ from one plan to the next. Requirements also change periodically without direct notice to providers, which is why payer guidelines need to be verified before every submission rather than assumed based on past experience. The number of services requiring prior authorization continues to grow, which makes verifying requirements before every submission a necessity, not a precaution.
How do you handle prior authorization for telehealth services?
Telehealth authorization requirements vary by payer and by state. Some payers require prior authorization for telehealth services, others do not, and the rules governing which services are eligible for telehealth reimbursement continue to shift. We verify payer-specific telehealth authorization rules before every submission so that a telehealth claim is never denied because the authorization process did not account for how that payer handles remote services.
What is the difference between prior authorization and prior notification?
Prior authorization requires the payer to review and approve a service before it is rendered. Prior notification, sometimes called prior notification only or PNO, requires the provider to inform the payer that a service will be rendered, but does not require approval before proceeding. The distinction matters because submitting an authorization request when only notification is required, or submitting a notification when approval is actually required, can both result in claim issues downstream.
Every denied authorization is fixable.
Let us show you how.
One conversation with our team will give you a clear picture of where your authorizations are failing and why fixing that process is essential for your practice.
