Patient access
Prior Authorization
Medical-benefit authorization administration from the requirement check through the recorded determination, performed within the practice’s systems by PriorDesk’s U.S.-based team.
Overview
Prior authorization is the payer’s requirement that a service be approved before it is delivered. For a practice it is a workflow with many parts: establishing whether authorization is required at all, identifying the payer or the utilization-management vendor that reviews on its behalf, assembling documentation that meets the payer’s published criteria, submitting through the channel that payer accepts, and following the request until a determination is recorded. PriorDesk owns that workflow for medical-benefit services: procedures and surgeries, diagnostic imaging, infusion services, injections, therapies, durable medical equipment, and specialty procedures.
Authorization sits at the center of payer administration. It depends on accurate eligibility and referral information upstream, and it bears on whether the claim will be paid downstream. PriorDesk manages it as part of one continuous record, so the authorization number, approved dates, units, and servicing location are documented where the practice can reconcile them against the claim.
What PriorDesk handles
Authorization workflow
- Authorization requirement determination
- Payer and third-party reviewer identification
- Documentation collection and administrative completeness review
- Portal, fax, and telephone submissions
- Status tracking, payer follow-up, and requests for additional information
- Urgent or expedited requests where permitted
- Retroactive authorization where the payer permits it
- Determination documentation in the practice’s system
Changes, verification, and escalation
- Authorization modifications, extensions, and renewals
- Verification of the authorization number, approved dates, approved units or visits, and servicing location
- Expiration tracking
- Denial escalation and hand-off to Denials & Appeals
- Reconsiderations, appeals, and peer-to-peer scheduling, administered under Denials & Appeals and priced per appeal
Where it sits in payer administration
Authorization rarely stands alone. Eligibility and referral checks establish whether authorization is required and whether the visit can be financially cleared; denial and appeal administration takes over when a request is refused; and medication requests that process under the pharmacy benefit follow a separate path.
Within your existing systems
PriorDesk performs this work inside the systems your practice authorizes for the assigned workflow: the EHR or practice-management system, payer portals, pharmacy benefit manager and specialty-pharmacy platforms, clearinghouses, CAQH and PECOS, and the payer telephone channels the work requires.
Your practice provisions the accounts, sets the permissions, and can modify or revoke access at any time. Nothing is moved into a separate PriorDesk patient database.
Reporting and accountability
PriorDesk documents payer activity within the practice-approved systems used for the engagement, with supplemental operational tracking where appropriate. That tracking is aggregate and contains no protected health information; patient-level case detail stays in your systems.
Reporting appropriate to the engagement covers case status, last payer action, next follow-up, deadlines, determinations, unresolved issues and escalations, and the administrative barriers that recur.
Service boundaries
PriorDesk performs the administrative workflow. The practice and its licensed clinicians retain:
- Medical-necessity determinations
- Prescribing and treatment decisions
- Clinical attestations and provider signatures
- Physician peer-to-peer clinical reviews
- Diagnosis and procedure code selection
- Clinical answers to payer questions
When a payer requests clinical input, PriorDesk documents the request, schedules the peer-to-peer where one is offered, prepares the administrative file, and routes the clinical conversation to the practice.
When work is scoped separately
Routine medical-benefit authorizations are included in the Authorization Desk and the Payer Desk plans. Work is scoped separately when it involves:
- Reconsiderations, formal appeals, and peer-to-peer scheduling, which are administered under Denials & Appeals and priced per appeal
- Retroactive authorization projects covering a backlog of dates of service
- Utilization-management vendor programs with practice-specific submission requirements
- Workers’ compensation or auto and no-fault authorization workflows
- Volume above the published plan tiers
Specialties where this work is concentrated
Get started with PriorDesk
Tell us about your practice, your approximate monthly volume, and the support you need. We review your workflow, confirm the scope, and send the agreement and onboarding documents. No patient information is requested or accepted.