How Can Practices Reduce Prior Authorization Denials?

Track which services need authorization by payer, check requirements before scheduling, log auth numbers on every claim, and monitor expirations to cut avoidable denials. MB Claims helps practices build authorization workflows that catch missing auth before claims go out. A structured auth workflow reduces rework, speeds reimbursement, and keeps billing staff focused on revenue recovery.

Which services commonly require prior authorization?

Advanced imaging (MRI, CT, PET), outpatient surgery, durable medical equipment, specialty drugs, genetic tests, and most inpatient admissions require prior authorization from commercial payers. Medicare Advantage plans often require auth for services Original Medicare does not. Each payer publishes a list of codes and service categories requiring authorization, and these lists change quarterly or annually.

• Advanced imaging (MRI, CT, PET)
• Outpatient surgery and certain procedures
• Durable medical equipment (DME)
• Specialty pharmaceuticals and infusions
• Genetic and molecular testing
• Inpatient admissions and observation stays

Medicare Advantage plans layer auth requirements onto the Original Medicare benefit, so a CPT code that does not require auth under traditional Medicare may need one under an MA contract. Practices should maintain a current master list by payer or integrate authorization requirements into scheduling prompts.

How should auth numbers be tracked?

Log the authorization number, approved CPT codes, units, date range, and issuing payer in both the practice management system and the patient chart so scheduling, clinical, and billing teams all see the same data. Use a shared spreadsheet or EHR task list for pending auths and set calendar reminders for expiration dates. When the auth arrives, attach the approval letter as a scanned document and update the claim file.

Authorization tracking fields:

• Auth number (exactly as the payer issued it)
• Approved CPT/HCPCS codes and units
• Valid date range (start and end)
• Issuing payer and plan name
• Date received and staff member who verified

Store the approval letter in the patient chart and flag the account in your PM system so front-desk and billing staff can confirm coverage before the visit. Set an automated alert before expiration if the patient needs ongoing treatment.

What should you do when an auth denial happens?

Review the EOB or remittance advice to identify whether the denial is for missing auth, expired auth, or service not matching the authorized code. If the service was clinically provided and the auth should have been obtained, file a timely filing appeal with supporting clinical records and request a retrospective review if the payer allows it. For future visits, update your payer-specific checklist and train front-desk staff.

Immediate steps:

1. Pull the claim, EOB, and any auth correspondence.
2. Confirm whether an auth was obtained and whether it matched the billed CPT.
3. If the auth was valid but the claim denied, call the payer to verify the auth number was transmitted correctly.
4. If no auth was obtained and the payer allows retro review, submit clinical notes and a written request within the timely filing window.
5. Document the root cause (scheduling miss, payer rule change, coding mismatch) and update your denial prevention checklist.

How do you prevent authorization denials at scheduling?

Integrate payer authorization requirements into your scheduling software so the system prompts staff when a CPT or visit type needs auth. Train front-desk and scheduling teams to verify eligibility and auth status during appointment booking and again during confirmation calls. Build a payer-specific quick-reference guide listing high-risk codes and the turnaround time each payer requires so staff know when to escalate urgent cases.

• Configure scheduling templates to flag high-auth services (imaging, surgery, infusions).
• Run real-time eligibility checks that include auth indicators when available.
• Use a shared task board or EHR worklist to track pending auth requests and follow-up dates.
• Assign one billing team member to monitor payer portals daily for auth approvals and denials.
• Schedule a monthly review of denied claims to identify patterns by payer, provider, or service line.

How MB Claims handles this

MB Claims builds authorization tracking workflows into every client engagement, starting with a payer-specific checklist of high-auth codes and scheduling prompts. The team monitors pending auths daily, logs approvals in the PM system, and flags accounts before expiration. When a denial occurs, MB Claims pulls the EOB and clinical documentation, files the appeal within payer deadlines, and updates the client's denial prevention protocol. Regular monthly audits identify patterns by payer and service line so practices can refine front-desk training and reduce repeat issues.

Frequently asked questions

Do all payers require prior authorization?

No. Original Medicare rarely requires prior authorization, but Medicare Advantage, Medicaid managed care, and commercial plans all maintain auth lists. Verify requirements by payer and update your checklist when contracts or policies change.

Can you bill a patient if authorization was denied?

Only if you obtained a signed advance beneficiary notice (ABN) or equivalent waiver before the service. Without a waiver, billing the patient for a denied auth may violate payer contract terms and federal balance-billing rules.

How long does prior authorization take?

Turnaround varies by payer and urgency. Routine requests may take several business days; expedited or urgent reviews can be completed faster if clinical documentation supports the request and the payer offers an urgent review pathway.

What happens if the auth expires mid-treatment?

Submit a continuation request with updated clinical notes before the expiration date. If the auth lapses, claims for dates after expiration will deny, and you may need a retro review or appeal to recover payment.

Should authorization tracking be part of credentialing?

No. Credentialing establishes contracts and enrollment; authorization tracking is an operational billing and scheduling function. Both must align so staff know which payers the provider can bill and which services require auth under each contract.

MB Claims · www.mbclaims.com

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