Prior Authorization

Yes. We work authorizations as a front-end step alongside eligibility verification: confirming when authorization is required for the patient's plan, gathering documentation that supports medical necessity, submitting the request, and following up with the payer until approval is on file before the claim goes out. It can run within full revenue cycle management or as part of the front-end work that feeds clean claims.

Requirements vary by payer, plan, and item, but power mobility, certain respiratory and CPAP setups, some orthotics and prosthetics, and select home health services commonly require authorization. We check the requirement for the specific patient's plan as a front-end step rather than assuming, since the same HCPCS code can require auth under one payer and not another. When a payer publishes a code or policy list, we work from it; when it does not, we confirm directly so nothing goes out unauthorized.

It depends on the item and payer, but typically the order or SWO, supporting chart notes that establish medical necessity, relevant diagnoses, and any payer-specific forms or LCD or NCD criteria the policy calls for. We assemble and align what exists and flag specific gaps back to your team rather than guessing or fabricating clinical detail. The goal is a request that matches the payer's medical-necessity standard the first time, so we are not stuck in avoidable back-and-forth.

We track the approval window and any approved quantity or unit limits as part of follow-up, so an expired or exhausted authorization does not turn into a held or denied claim. For recurring or rental items, that means watching the timeline against your delivery and resupply schedule. If a renewal or additional units are needed, we work the new request ahead of the date rather than after a denial.

We do not just record the no. We read the payer's reason, identify whether it is a documentation gap, a medical-necessity question, or a policy mismatch, and work the additional-information, peer-to-peer, or appeal path the payer allows. Because we also run denial management, an authorization problem can flow straight into that workflow instead of being dropped. We are honest that not every request is approvable, but we make sure each one gets a complete, well-supported effort.

Yes. We work as an extension of your office inside your existing EHR or practice management and the payer portals, so authorizations live where your team already looks and there is no separate system to learn or reconcile. We adapt to your software and naming conventions rather than asking you to change platforms. If you use a clearinghouse or payer portal for submissions, we work there too.

They run together. The same eligibility check that confirms active coverage and a covered benefit also surfaces whether the plan requires authorization, so we can start the request early instead of discovering the requirement after a claim is denied. Catching it at the eligibility stage is how missing-auth and non-covered surprises get caught before delivery rather than after. Pairing the two keeps front-end work moving as one step instead of two disconnected checks.

Pricing is scoped to your specialty, payer mix, and volume and is shared on a consult rather than posted publicly, because a single-payer DME line and a multi-specialty practice are very different efforts. Authorization can run as a standalone front-end service or as part of broader front-end work and full revenue cycle management. We will talk through your actual auth volume and the realistic scope before quoting anything.

Yes. We operate under HIPAA and sign a Business Associate Agreement before handling protected health information, since authorization work involves clinical documentation and patient detail. We also never collect or store PHI through web forms; that exchange happens through agreed, secure channels once we are engaged. Compliance is a precondition of the work, not an add-on.

You get visibility into where each request stands: what is approved, what is pending payer response, and what is waiting on documentation from your clinicians, so nothing sits unseen. We surface the specific items we need from your team rather than letting a request stall silently. The exact reporting format and cadence are set during onboarding to fit how your office already tracks work.