Obtaining prior authorizations is one of the biggest headaches in any medical office. It’s time-consuming, frustrating, and—let’s be honest—completely unavoidable. Whether it’s for medications, diagnostic imaging, or additional treatments, every practice will run into prior authorizations at some point. So instead of dreading them, let’s break down how to make obtaining prior authorizations more efficient and keep your office running smoothly.

Key Takeaways

• Prior authorizations are unavoidable but can be managed efficiently with the right workflow.
• Use your EHR system to track authorizations and avoid denials.
• Know the requirements for different services (imaging, prescriptions, specialist visits).
• Assign the right staff—not front desk workers, but trained medical assistants or authorization coordinators.
• Follow up regularly with insurance companies to prevent unnecessary delays.
• Train your team on insurance portals, documentation, and tracking approvals.

Why Obtaining Prior Authorizations Matters (Even If It’s a Pain)

Prior authorizations exist to control costs—at least that’s what insurance companies say. In reality, they often delay necessary treatments, create extra work for your staff, and add frustration for both patients and providers. But since obtaining prior authorizations is non-negotiable, you need a solid workflow to handle them efficiently.

Before your practice even opens, decide who will be responsible for obtaining prior authorizations. This ensures there’s no confusion when a request comes in. A well-structured process can prevent denials, speed up approvals, and keep patient care on track.

Using Your EHR to Track Prior Authorizations

Before you do anything else, check your EHR system. Some electronic health record (EHR) systems have built-in tracking features that can help with obtaining prior authorizations. If your system allows it, make sure it:

• Keeps a log of pending and approved authorizations
• Links authorization numbers to patient claims
• Alerts your staff when an authorization is about to expire

This is crucial, especially for services your office provides directly. Without the correct authorization number on a claim, the insurance company won’t pay. That’s an easy (and expensive) mistake to avoid.

How to Obtain Prior Authorizations Based on Service Type

Obtaining prior authorizations isn’t one-size-fits-all. The process depends on the type of service or medication and the insurance company involved. Here’s what you need to know:

1. Advanced Imaging (CT, MRI, PET Scans, etc.)

For diagnostic imaging, most insurance companies use third-party portals to process requests. Your staff will need to provide:

• The exact imaging study requested (with or without contrast)
• CPT codes for the procedure
• Relevant diagnosis codes
• Details of previous conservative treatments (if applicable)
• Symptoms and medical necessity
• The imaging facility’s details (name, address, and network status)

Once approved, the authorization is usually valid for a month, so be sure to schedule the patient within that timeframe.

2. Prescription Medications

If the medication isn’t on the insurance company’s preferred formulary, you’ll need prior authorization. One of the best tools for this is CoverMyMeds—a universal portal that allows staff to submit authorization requests electronically.

To speed up approval, make sure your provider’s chart notes document the following:

• Previous medications tried and failed
• Lab results that support the need for the requested medication
• Any relevant symptoms or conditions

3. Additional Visits (Physical Therapy, Specialist Appointments, etc.)

If a patient needs more visits than their insurance plan typically allows, you’ll need to justify why. This might include:

• Progress notes showing the patient hasn’t plateaued
• Documentation of continued medical necessity
• A treatment plan detailing why more visits are required

For all prior authorization requests, the more complete and detailed the documentation, the faster the approval.

Who Should Be in Charge of Obtaining Prior Authorizations in Your Office?

Now that we’ve covered the why and how of obtaining prior authorizations, let’s talk about who should actually be responsible for handling them. This is a critical decision because the person managing prior authorizations needs to understand clinical details, insurance requirements, and office workflows.

If you’re just starting out and don’t have a high patient volume yet, your back-office staff can handle obtaining prior authorizations. But as your practice grows, you’ll need a more structured approach.

Front Office vs. Back Office: Who Should Handle Prior Authorizations?

The bottom line? Don’t dump prior authorizations on your front desk staff unless they have clinical experience. If the person handling them doesn’t understand diagnosis codes, CPT codes, or why a certain treatment is necessary, it’ll lead to denials, delays, and frustrated patients.

Training Your Staff to Handle Prior Authorizations Like a Pro

If your back-office staff has never done prior authorizations before, they’ll need training. Many large hospital systems have dedicated teams for authorizations, so if your new hires come from a big institution, they may not have experience navigating insurance portals or third-party approval sites.

Here’s what your team needs to be trained on:

How to Use Insurance Portals and Third-Party Authorization Platforms

Most insurance companies use a third-party system (like AIM, Evicore, or CareCore) to process imaging and procedure authorizations. Others require prior authorizations directly through their own portal.

Your staff should:

• Create logins for all major insurance and third-party portals
• Understand how to navigate them to submit and track authorizations
• Know how to retrieve authorization numbers and attach them to claims

What Information Is Needed for a Clean Authorization Request

Every denied authorization is a waste of time and a delay in patient care. To avoid this, train staff on:

• Which CPT and diagnosis codes are required
• How to document failed conservative treatments
• Where to find the necessary info in the patient’s chart
• How to correctly fill out medication authorization forms

The Importance of Documentation in the Patient’s Chart

Your provider’s notes can make or break an authorization request. If they don’t properly document failed treatments, symptoms, and medical necessity, the request will likely be denied or delayed.

Train your staff to review chart notes before submitting authorizations. If the documentation is missing key details, they should request an addendum from the provider before submitting.

Setting Up a Foolproof Workflow for Obtaining Prior Authorizations

Having clear policies and procedures ensures your staff knows exactly what to do when a prior authorization is needed. Here’s a simple workflow your practice can implement:

Identify If Prior Authorization Is Needed

• Check insurance requirements before scheduling the service or prescribing a medication.

Gather All Necessary Information

• For imaging and procedures: CPT codes, diagnosis codes, past treatment history, symptoms, and provider notes.
• For medications: Prior medications tried and failed, lab results, medical necessity explanation.

Submit the Authorization Request

• Use the correct portal or insurance website.
• Attach supporting documentation to avoid delays.

Track the Status and Follow Up

• Check for approval within the expected timeframe.
• Follow up proactively if the request is still pending.

Add Authorization Number to Patient’s Chart & Billing System

• Ensure the correct number is included when submitting claims to insurance.
• This prevents unnecessary claim denials.

FAQ: Obtaining Prior Authorizations

Navigating the prior authorization process can be a headache, but having clear answers can make it easier. Here are some frequently asked questions about obtaining prior authorizations and how to streamline the process in your practice.

What is a prior authorization, and why is it required?

A prior authorization (PA) is a process where a healthcare provider must get approval from an insurance company before a medication, procedure, or service is covered.

Insurance companies require PAs to:

• Control costs
• Ensure medical necessity
• Encourage the use of preferred treatments before approving more expensive options

Without approval, insurance may deny payment, leaving the patient responsible for the full cost.

What types of services require prior authorization?

The most common services that require prior authorization include:

• Advanced imaging (MRI, CT scans, PET scans, etc.)
• Non-formulary prescription medications
• Specialist visits and additional therapy sessions (e.g., physical therapy, chiropractic care)
• Surgical procedures and high-cost treatments

Each insurance plan has different rules, so always check before scheduling a service.

How do I know if a prior authorization is required?

You can check if prior authorization is needed by:

• Looking up the patient’s insurance policy on the insurance company’s website
• Using your EHR system if it has built-in authorization tracking
• Calling the insurance provider directly
• Checking online portals like CoverMyMeds for medication authorizations

If you skip this step and assume a PA isn’t needed, you might delay the patient’s treatment and risk a claim denial.

How long does it take to obtain a prior authorization?

It varies based on:

• The insurance company (some process approvals within 24 hours, while others take weeks)
• The urgency of the request (emergency approvals can be expedited)
• How complete the submission is (missing information causes delays)

On average:

If your request is taking longer than expected, call the insurance company to check the status.

What happens if a prior authorization is denied?

If a PA is denied, don’t panic—you have options:

• Review the denial reason: It could be missing information, an incorrect diagnosis code, or an alternative treatment requirement.
• File an appeal: If you believe the service is necessary, submit an appeal with additional documentation and supporting evidence.
• Request a peer-to-peer review: A physician can discuss the case with an insurance medical director to fight for approval.
• Check for alternative treatments: Some medications and services have preferred alternatives that don’t require prior authorization.

If denied, always inform the patient quickly so they understand their options.

Who in my office should be responsible for obtaining prior authorizations?

It depends on the size of your practice:

• Small offices: Medical assistants (MAs) or nurses should handle it.
• Large offices: A dedicated prior authorization specialist is ideal.
• Front desk staff? NO! They usually don’t have the medical knowledge needed to provide the right information.

Make sure whoever handles prior authorizations is trained in insurance processes, documentation, and tracking approvals.

Can an EHR system help with prior authorizations?

Yes! Many electronic health record (EHR) systems have tools that:

• Track pending authorizations
• Store authorization numbers
• Alert staff when reauthorization is needed
• Auto-populate claims with the correct PA number

Check your EHR settings or contact your software provider to see what features are available.

How can I speed up the prior authorization process?

To avoid delays, follow these best practices:

• ✅ Submit complete and accurate information (CPT codes, diagnosis codes, clinical history)
• ✅ Use electronic portals instead of faxing (CoverMyMeds, insurance websites, third-party PA platforms)
• ✅ Track requests daily and follow up if they are taking too long
• ✅ Train staff on different insurance requirements and documentation needs
• ✅ Get providers to document clearly (insurance companies reject vague notes!)

The more organized and proactive your office is, the faster you’ll get approvals.

What if my patient needs an urgent prior authorization?

If a service is urgent and waiting could harm the patient, you can request an expedited review.

• Call the insurance company and state that the request is urgent
• Have the provider send a letter explaining why the delay is harmful
• Use the insurance company’s expedited PA request form if available
• Follow up within 24 hours to ensure it’s processed quickly

Emergency cases often get approved faster, but documentation is key!

What are the most common mistakes when obtaining prior authorizations?

🚨 Top mistakes that lead to delays or denials:

• ❌ Submitting the wrong CPT or diagnosis code – Always double-check coding.
• ❌ Not providing enough supporting documentation – Explain medical necessity clearly.
• ❌ Waiting too long to follow up – Don’t assume the insurance will approve it quickly.
• ❌ Forgetting to include the authorization number on claims – This leads to payment rejections.
• ❌ Not checking if the provider is in-network – Some insurance plans only approve services at certain facilities.

Avoid these mistakes, and you’ll speed up approvals and prevent unnecessary denials.

Final Thoughts: Efficiency is Everything

Obtaining prior authorizations doesn’t have to be a never-ending nightmare. With the right staff, training, and workflow in place, your office can handle them efficiently and avoid frustrating delays.

Mastering the prior authorization process takes time, but a solid workflow can save your staff hours of frustration.

Still have questions? Drop them in the comments!