Prior Authorization Guide
Step-by-step guidance for navigating prior authorization requirements
Prior Authorization Quick Start
Essential steps to obtain authorization from any payor
Verify Requirements
Check if the service requires prior authorization for the specific payor and plan
Gather Information
Collect patient info, diagnosis codes, CPT codes, and clinical documentation
Submit & Track
Submit via portal, phone, or fax. Document authorization number and track status
Information Needed for Authorization
Patient Information
- Full name and date of birth
- Member/Policy ID number
- Group number (if applicable)
- Contact information
Clinical Information
- Diagnosis codes (ICD-10)
- Procedure/service codes (CPT/HCPCS)
- Medical necessity documentation
- Requested service dates
- Place of service
Supporting Documentation
Clinical notes, test results, treatment history, and any prior failed treatments should be ready to submit if requested.
Authorization by Major Payor
Aetna
UnitedHealthcare
Cigna
Common Authorization Issues
Incomplete Information
Missing diagnosis codes, incorrect CPT codes, or insufficient medical records. Always double-check all fields before submission.
Medical Necessity Not Established
Clinical documentation doesn't support the requested service. Include detailed notes explaining why the service is medically necessary.
Service Not Covered
The requested service may not be covered under the patient's specific plan. Always verify benefits before requesting authorization.
Best Practices
Submit Early
Request authorization as soon as service is scheduled, not the day before
Document Everything
Keep authorization numbers, submission dates, and reference numbers in patient charts
Follow Up
If no response within expected timeframe, call to check status
Appeal if Denied
If authorization is denied, submit an appeal with additional clinical justification