A Prior Authorization Checklist for Busy Clinics
Prior authorization is a payer's approval for a service before it is delivered. When it is missed, the claim is often denied and the practice absorbs the cost. A repeatable checklist removes most of that risk.
Why authorizations fail
Most failures are process issues: nobody checked whether a requirement existed, information was incomplete, or the approval did not match the date, provider or location of the service.
Before you schedule
Run through these checks:
- Is authorization required for this code with this plan?
- Is the provider in network and enrolled?
- Which clinical information do the payer's criteria ask for?
- How long does the payer usually take to decide?
What to include
Incomplete requests are the most common reason for delay. Include:
- Patient and plan identifiers
- Ordering provider and facility details with NPI
- Diagnosis and procedure codes
- Clinical notes, imaging and previous treatments tried
- Requested dates and number of visits
After you submit
Record the reference number and the expected decision date, and set a reminder to follow up. Approvals should list the approved codes, dates and units. Check they match what is scheduled.
If it is denied
Request the denial reason in writing, check the payer's appeal deadline and consider a peer-to-peer conversation between your clinician and the payer's reviewer. Attach new evidence that addresses the stated reason.
Keep a tracker
A simple log of requests, status and decisions shows which payers and procedures cause the most delays. That information helps scheduling and pays for itself quickly.
Example: scheduling an MRI
Before booking, the team checks the plan's requirement for the imaging code, confirms the ordering provider is in network, gathers the clinical notes and submits the request. The reference number is saved on the appointment, and the scheduler is alerted if no decision arrives by the expected date.
Frequently asked questions
Who should own authorizations?
Assign a named owner for each payer or specialty, so requests are never assumed to be someone else's job.
What if an urgent patient cannot wait?
Contact the payer about expedited review and document the clinical urgency.
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