🔐 Prior Authorization Workflow

To establish a standardized process for identifying, submitting, monitoring, and completing prior authorization requests to minimize delays in patient care, improve payer compliance, and ensure accurate documentation within RXNT.

Purpose

Many medications, procedures, imaging studies, and specialty services require insurance approval before services can be provided. A standardized prior authorization process helps reduce treatment delays, improve communication with patients, and increase approval success while maintaining compliance with payer requirements.

Policy

All prior authorization requests must be initiated promptly after the provider places the order or prescribes the treatment. Every authorization request must be documented, monitored, and followed through to a final determination.

Prior Authorization Workflow

1️⃣ Provider Orders Service
2️⃣ Verify Insurance
3️⃣ Determine PA Requirement
4️⃣ Submit Authorization
5️⃣ Monitor Status
6️⃣ Receive Decision
7️⃣ Notify Patient & Provider
8️⃣ Document in RXNT

Services Commonly Requiring Prior Authorization

Medications

  • Brand-name medications.
  • GLP-1 medications.
  • Injectable medications.
  • Biologic therapies.
  • High-cost specialty medications.
  • Certain controlled medications when required.

Diagnostic Services

  • MRI.
  • CT scans.
  • PET scans.
  • Sleep studies.
  • Genetic testing.
  • Advanced laboratory testing.

Procedures & Services

  • Infusion therapy.
  • Durable Medical Equipment (DME).
  • Specialty referrals.
  • Physical therapy.
  • Occupational therapy.
  • Other payer-designated services.

Medical Assistant Responsibilities

  • Review the provider's order for completeness.
  • Verify the patient's insurance eligibility.
  • Determine whether prior authorization is required.
  • Collect all supporting clinical documentation.
  • Submit the authorization using the payer's required method.
  • Document the submission date in RXNT.
  • Create follow-up reminders until a determination is received.
  • Notify the provider when additional documentation is requested.

Best Practice

Submit prior authorizations on the same business day whenever possible. Early submission significantly reduces treatment delays and provides additional time to respond to payer requests for clinical documentation.

Clinical Documentation Requirements

Prior authorization requests should include sufficient documentation to support medical necessity.

  • Provider office note.
  • Relevant diagnosis codes.
  • Clinical history.
  • Previous treatments and outcomes.
  • Medication history when applicable.
  • Laboratory or imaging results.
  • Current medication list.
  • Supporting medical records requested by the payer.
Incomplete documentation is one of the leading causes of prior authorization delays and denials. Review submissions carefully before transmitting them.

Immediate Escalation Required

  • Urgent or STAT treatment requests.
  • Potential delays that may compromise patient safety.
  • Insurance denial of medically necessary treatment.
  • Peer-to-peer review requested by the payer.
  • Appeal requested by the provider.
  • Authorization expiration before treatment can be completed.
  • Repeated payer requests for additional documentation.
Notify the ordering provider immediately whenever payer decisions or delays may affect timely patient care. Expedited review, peer-to-peer discussion, or an appeal may be necessary.

Authorization Status Monitoring

Prior authorization requests should be monitored until a final determination has been received. Requests should never remain pending without documented follow-up.

📨 Authorization Submitted
⏳ Pending Review
📄 Additional Information Requested
✅ Approved or Denied
📞 Patient & Provider Notified
📝 Document & Close
TNC Standard

Every prior authorization request should remain on an active follow-up list until a final payer determination has been received and documented. No authorization request should be considered complete until the patient, provider, and applicable departments have been notified.

Approval Process

Once an authorization is approved, staff should promptly coordinate the next steps to prevent unnecessary treatment delays.

  • Document the authorization number.
  • Record the approval and expiration dates.
  • Notify the ordering provider.
  • Notify the patient of the approval.
  • Schedule or coordinate the approved service.
  • Update the authorization status within RXNT.
  • Ensure the receiving facility has the authorization information when applicable.

Best Practice

Schedule approved services as soon as reasonably possible. Waiting too long after approval may result in authorization expiration and require the process to begin again.

Denied Authorizations

Denials should be reviewed promptly to determine the appropriate next steps.

  • Review the payer's reason for denial.
  • Notify the ordering provider.
  • Determine whether additional documentation is available.
  • Complete peer-to-peer review when requested by the provider.
  • Submit an appeal when medically appropriate.
  • Document all appeal activity in RXNT.
  • Notify the patient of delays when appropriate.

Immediate Escalation

  • Life-sustaining treatment denied.
  • Urgent imaging or procedures denied.
  • Cancer-related treatment delays.
  • Repeated denials despite supporting documentation.
  • Peer-to-peer deadlines approaching.
  • Appeal filing deadlines approaching.

Patient Communication

Patients should be kept informed throughout the authorization process to reduce confusion and improve satisfaction.

  • Explain when prior authorization is required.
  • Provide realistic expectations regarding processing time.
  • Inform patients when additional information has been requested.
  • Notify patients of approval or denial promptly.
  • Provide next steps after the payer decision.
  • Document all patient communication in RXNT.
Insurance review timelines vary by payer. Staff should avoid guaranteeing approval dates or treatment start dates until authorization has been confirmed.

Documentation Requirements

  • Date authorization was initiated.
  • Insurance carrier.
  • Requested medication, procedure, or service.
  • Ordering provider.
  • Supporting clinical documentation submitted.
  • Authorization reference number.
  • Approval, denial, or pending status.
  • Approval and expiration dates when applicable.
  • Appeal activity.
  • Patient notifications.
  • Final disposition documented in RXNT.
Accurate documentation creates a complete record of payer communication and supports continuity of care, billing accuracy, and future audits.

Quality Assurance

Medical Assistant / Authorization Coordinator

  • Submit complete authorization requests.
  • Monitor pending authorizations.
  • Respond to payer requests.
  • Maintain documentation.
  • Communicate updates to patients and providers.

Provider

  • Provide supporting clinical documentation.
  • Complete peer-to-peer reviews when necessary.
  • Determine medical necessity for appeals.
  • Review alternative treatment options when appropriate.
  • Support timely patient care.

Leadership

  • Monitor authorization turnaround times.
  • Audit documentation quality.
  • Identify recurring payer issues.
  • Support process improvement initiatives.
  • Ensure staff education on payer requirements.

Prior Authorization Checklist

✅ Verify insurance eligibility
✅ Determine authorization requirements
✅ Collect all supporting documentation
✅ Submit complete authorization request
✅ Document submission in RXNT
✅ Monitor authorization status
✅ Respond to payer requests promptly
✅ Notify provider and patient of determination
✅ Coordinate approved services
✅ Document final outcome and close the authorization

Sawubona Standard

Prior authorizations are more than an insurance requirement—they are a critical step in helping patients access medically necessary care. At The Neighborhood Clinic, we proactively manage every authorization from submission through final determination, communicate openly with our patients, and work collaboratively with providers and payers to minimize delays. Every completed authorization reflects our commitment to timely, compassionate, and coordinated healthcare.