Services
Managed payer administration for medical practices and healthcare organizations.
PriorDesk manages the administrative relationship between practices and payers, from patient access and treatment authorization through reimbursement, appeals, provider enrollment, and payer participation. Eight service lines, engaged individually or combined within a defined written scope.
Eight service lines in three areas
Patient access
Coverage, referrals, authorization, and medication access, addressed ahead of scheduled care.
Reimbursement
Payer-facing claims, accounts receivable, denials, and appeals after care is delivered.
Provider and payer operations
The credentials, enrollments, and contracts that keep providers participating with payers.
How services are engaged
Not every service line is included in every monthly plan. Work is structured in the form that fits it:
- Recurring managed support: Individual service desks and Payer Desk plans with a defined monthly capacity for authorization, eligibility and benefits, and claims follow-up.
- Standard case work: The routine cases those plans are built around, counted against the monthly allowance.
- High-touch and complex cases: Cases that require substantially more work than a routine case, such as multi-level appeals or specialty medication access, scoped and priced on their own terms.
- Project-based services: Credentialing and enrollment projects, privileging, licensing, and payer recovery work with a defined start and finish.
- Custom-scoped engagements: Payer contracting and network administration, and any engagement that does not fit a published plan, scoped in writing after review.
Patient access
Coverage, referrals, authorization, and medication access, addressed ahead of scheduled care.
Eligibility, Benefits & Financial Clearance
Coverage, service-level benefits, and pre-service financial-clearance status, verified through approved payer channels and documented within the practice’s workflow.
PriorDesk verifies active coverage and service-level benefits ahead of scheduled care, using payer portals and direct payer contact where portal data is insufficient. Verification results, patient-responsibility estimates, and financial-clearance status are documented in the practice’s system.
Includes
- Active coverage, plan, and coordination-of-benefits identification
- Service-level benefits: deductible, copay, coinsurance, out-of-pocket maximum
- Referral and authorization requirement checks
- Patient-responsibility estimates from available payer information
- Documented pre-service financial-clearance status
Available individually through the Eligibility & Benefits Desk or within a Payer Desk plan.
Eligibility, Benefits & Financial Clearance in detail Discuss Eligibility & Benefits
Referral Management
Payer referral requirements identified, obtained, tracked, and documented alongside authorization and scheduling.
PriorDesk determines whether a payer referral is required, identifies missing referrals, coordinates the documentation needed to obtain them, and tracks each referral through its authorized visits, units, and expiration. Referral issues that could prevent financial clearance are identified and flagged to the practice.
Includes
- Referral requirement determination by payer and plan
- Missing-referral identification and documentation requests
- Tracking of visits, units, effective dates, and expiration
- Referral renewal and status follow-up
- Coordination with authorization and scheduling
Available by scope, individually or alongside eligibility and authorization services.
Medication Access & Pharmacy Benefits
Pharmacy-benefit administration and specialty medication access, coordinated across the payer, PBM, manufacturer hub, and specialty pharmacy.
Medications processed under the pharmacy benefit follow a different administrative path from medical-benefit services. PriorDesk determines which benefit applies, verifies pharmacy benefits, administers pharmacy-benefit and specialty-drug prior authorizations and exceptions, and manages the enrollment and status work that specialty medication access requires.
Includes
- Medical-versus-pharmacy benefit determination
- Pharmacy-benefit, specialty-drug, and biologic prior authorization
- Formulary and step-therapy exception administration
- Benefits investigation and specialty-pharmacy identification
- Hub, copay-card, and assistance-program enrollment
- Status tracking across payer, PBM, hub, and pharmacy
Available by scope. Medication access engagements are scoped to the practice’s medication mix, payer environment, and volume.
Medication Access & Pharmacy Benefits in detail Discuss Medication Access
Reimbursement
Payer-facing claims, accounts receivable, denials, and appeals after care is delivered.
Claims & A/R Administration
Payer-facing claim status, aging accounts-receivable follow-up, and payment-variance investigation and recovery support, documented through the payer workflow.
PriorDesk follows submitted claims through the payer’s process: researching status, resolving missing-information requests and administrative holds, pursuing stalled and aging claims, and tracking payer commitments through the payer’s final determination. Underpayments, contract variances, and recoupments are identified and followed up with the payer; whether a variance is recovered is decided by the payer. Corrected claims and resubmissions are coordinated when the practice or its billing system supplies the corrected billing information.
Includes
- Claim-status research and payer follow-up
- Pending, stalled, and aging claim follow-up
- Missing-information resolution and administrative hold follow-up
- Underpayment, zero-pay, and recoupment follow-up
- Corrected-claim coordination when billing information is supplied
- Aging and payer trend reporting
Routine claim follow-up is available through the Claims & A/R Desk or within a Payer Desk plan. Underpayment recovery follow-up and recoupment response projects are scoped separately.
Denials & Appeals
Denial research, appeal administration, and deadline tracking, with root causes reported back to the practice.
PriorDesk researches and categorizes each denial, assembles the appeal packet with the supporting documents the practice provides, submits reconsiderations and appeals, tracks deadlines and status, and documents the outcome. Denial trends are reported so that repeat administrative denials can be reduced at the source.
Includes
- Denial-reason research and categorization
- Reconsiderations and first-level appeals
- Appeal packet assembly and submission
- Deadline tracking and payer escalation
- Peer-to-peer scheduling and administrative preparation
- Outcome documentation and denial trend reporting
Priced per appeal or in appeal packs, separately from monthly case allowances.
Provider and payer operations
The credentials, enrollments, and contracts that keep providers participating with payers.
Credentialing & Payer Enrollment
Credentialing administration, payer enrollment, licensing, and privileging support for provider participation and network readiness.
PriorDesk administers provider credentialing files, CAQH profiles, and payer enrollment across commercial, Medicare, Medicaid, Medicare Advantage, and managed-care programs, and follows each application through to the payer’s determination. Related enrollments, expirable tracking, and revalidation are maintained to reduce the risk of lapsed participation.
Includes
- Credentialing files, CAQH, and recredentialing
- Commercial, Medicare, Medicaid, and managed-care enrollment
- Revalidation, roster, and demographic maintenance
- EFT, ERA, and clearinghouse enrollment
- Licensing and privileging administration
Priced per provider, per payer, or as a defined enrollment package. Licensing and privileging projects are scoped separately.
Credentialing & Payer Enrollment in detail Discuss Credentialing & Enrollment
Payer Contracting & Network Administration
Participation requests, contract administration, fee-schedule review, and negotiation support, tracked within the organization’s designated workflow.
PriorDesk administers the practice’s participation with payers: new participation and network applications, contract status, fee-schedule collection and review, renewal and amendment tracking, and coordination of negotiation with the payer. Persistent payer administrative issues are escalated through the contract relationship.
Includes
- Participation requests and network applications
- Contract administration and status follow-up
- Fee-schedule collection and review
- Renewal and amendment tracking
- Negotiation support and coordination
Custom scoped.
Payer Contracting & Network Administration in detail Discuss Payer Contracting
Supported payer and workflow environments
PriorDesk administrative services can support workflows involving:
- Commercial insurance
- Medicare
- Medicare Advantage
- Medicaid
- Medicaid managed care
- Medical benefits
- Pharmacy benefits and PBMs
- Specialty medications and biologics
- Infusion therapy
- Imaging
- Surgery and procedures
- Durable medical equipment
- Therapy services
- Workers’ compensation, where scoped
- Auto and no-fault, where scoped
The payers, programs, and workflows included in an engagement are defined in the written scope. Not every payer, state program, or specialty workflow is included in every plan.
What PriorDesk does not provide
PriorDesk performs administrative payer functions. It is not a medical billing company, a staffing agency, a call center, or a virtual assistant service, and it does not perform clinical functions.
Not offered:
- Medical coding and charge entry
- Full-service medical billing, patient collections, or patient statement processing
- Appointment scheduling, virtual receptionists, or general virtual assistants
- Medical scribing, transcription, or clinical documentation
- Remote patient monitoring
- Bookkeeping, accounting, marketing, or website services
- General back-office outsourcing
Retained by the practice and its licensed clinicians:
- Clinical decision-making and treatment recommendations
- Medical-necessity determinations and prescribing decisions
- Diagnosis and procedure code selection, code changes, or coding recommendations
- Physician peer-to-peer clinical reviews
- Provider signatures, attestations, and clinical answers to payer questions
- Representation as the treating provider
Where a case requires clinical input, PriorDesk returns the question or request to the appropriate practice representative. Work outside the written service scope requires practice approval.
How every engagement is structured
Written scope and pricing
The included services, responsibilities, case capacity, exclusions, and pricing are documented before service begins.
U.S.-based administrative support
Contracted payer-administration work is performed by personnel located in the United States through practice-approved systems and payer workflows.
Practice-controlled access
The practice provisions, controls, and can revoke the system accounts and permissions used by PriorDesk.
Work inside authorized systems
Payer-administration activity is documented in the practice’s authorized workflow.
Business Associate Agreement
The Business Associate Agreement and applicable security, training, device, and access requirements are completed before PriorDesk begins live work involving protected health information.
Approved additional work
Services outside the agreed scope require practice approval before they are performed.
Begin with a clear scope
Tell us which payer-administration workflows you want help with, your approximate monthly volume, and the size of your organization. We will review the scope and determine whether PriorDesk is a fit.
No patient information is requested or accepted through this website.
PriorDesk does not guarantee payer approval or payer response time.
Business Associate Agreement before access
Practice-controlled system access
U.S.-based personnel
Documented in your authorized system