Prior Authorization Services

Prior Authorizations Off Your Desk — and Approved Before the Visit.

Practices complete nearly 40 prior authorization requests per physician every week, and almost every physician says the process delays care. MedVersify takes that work over: we check whether an auth is needed, submit it on the payer’s portal or the utilization-management vendor’s, chase it until it’s decided, and appeal it when it’s denied.

Auth requirement checked at scheduling
Submission on payer and UM-vendor portals
Daily status follow-up until a decision
Peer-to-peer reviews scheduled for your providers
Denials appealed with the clinical record
Auth number, units, and dates matched to the claim

Get a Free Review (507) 312-9282

The Prior Authorization Burden

Prior Authorization Is the Fastest-Growing Job in Your Front Office

Prior Authorizations per Physician, per Week

Practices complete an average of 39 prior authorization requests per physician every week — nearly 40 forms, calls, and portal submissions.

American Medical Association, 2025

93%

Of Physicians Say Prior Auth Delays Care

Nearly every physician surveyed by the AMA reports that prior authorization delays patients’ access to necessary care.

AMA Prior Authorization Physician Survey

52.8M

Medicare Advantage Prior Auth Decisions in 2024

Medicare Advantage insurers made 52.8 million prior authorization determinations in 2024 and denied 4.1 million of them (7.7%).

KFF analysis of CMS data, 2026

80.7%

Of Appealed MA Denials Overturned

Four in five appealed Medicare Advantage prior authorization denials were reversed in whole or in part — yet only 11.5% were appealed.

KFF analysis of CMS data, 2026

What’s Included

End-to-End Prior Authorization, From Scheduling to Payment

Prior authorization is included in our full medical billing service and is also available on its own. Either way, the authorization is linked to the claim, so a valid auth never turns into a CO-197 denial because the units, dates, or CPT code don’t match.

Requirement check at scheduling

When a visit, procedure, imaging study, or referral is booked, we check the patient’s plan rules to see whether an authorization is needed — and how long the payer usually takes — so the date can be set realistically.

Benefit VerificationPayer Policy Lookup

Submission on every portal

Payer portals, phone and fax payers, and utilization-management vendors such as eviCore and Carelon. Where a payer supports electronic prior authorization, we use it.

Payer PortalsUM VendorsePA

Clinical packet assembly

We pull the notes, imaging, conservative-treatment history, and test results the payer’s criteria ask for, so the request is complete on the first submission instead of pended for more information.

Medical NecessityClinical Criteria

Daily status follow-up

Pending requests are checked every business day. If a decision is overdue under the payer’s required timeframe, we escalate.

72-Hour / 7-Day ClocksEscalation

Peer-to-peer scheduling

When a payer offers a peer-to-peer review, we book it into your provider’s calendar and prepare a one-page brief on the criteria the reviewer is likely to focus on.

Peer-to-PeerReviewer Brief

Denial appeals

Denied requests are appealed with the clinical record and the payer’s own policy. For Medicare Advantage, Medicaid, and CHIP plans, the payer now has to give a specific reason for the denial, which makes appeals sharper. See our denial management service.

AppealsSpecific Denial Reasons

Auth-to-claim matching

Before billing, the authorization number, approved CPT codes, units, and date range are checked against the claim. Extensions are requested before an authorization expires, not after.

Auth NumberUnitsDate Span

WISeR model support

In the six states running Medicare’s WISeR model, we handle the prior authorization request or prepare the claim for pre-payment review. Read our WISeR guide.

Traditional MedicareSix States

Reporting on turnaround and approvals

Monthly reporting on volume, approval rate, average turnaround by payer, and appeals won — the numbers you need to push back in contract talks.

Turnaround by PayerApproval Rate

Reference

Which Prior Authorization Rules Apply to Which Payer in 2026

The single most common mistake we see is citing the wrong rule to the wrong payer. CMS-0057-F only binds plans CMS regulates, traditional Medicare has its own short list, and commercial plans follow their contract and state law. Our full guide to CMS-0057-F goes deeper.

Prior authorization rules by payer type

Payer type	Decision deadline	What applies
Medicare Advantage	72 hours expedited · 7 calendar days standard	CMS-0057-F since January 1, 2026: specific denial reasons and public prior-auth metrics. Prior Authorization API due January 1, 2027.
Medicaid & CHIP (fee-for-service and managed care)	72 hours expedited · 7 calendar days standard	CMS-0057-F, unless state rules are stricter. Medicaid managed care plans follow the same deadlines.
Exchange plans on HealthCare.gov (FFE QHPs)	Existing ACA review timelines	Covered by the CMS-0057-F API, denial-reason, and reporting rules, but excluded from the new 72-hour/7-day decision deadlines.
Traditional Medicare (fee-for-service)	Set per program	Prior auth only for specific hospital outpatient services, certain DMEPOS items, repetitive scheduled non-emergent ambulance transport, and the WISeR model in six states.
Commercial & employer plans	Set by contract and state law	Not covered by CMS-0057-F. Many states have their own timelines and “gold card” exemptions for providers with high approval rates.

Source: CMS-0057-F fact sheet (CMS, 2024). Prescription drugs are excluded from CMS-0057-F entirely.

Traditional Medicare services that need prior authorization in a hospital outpatient department

This list applies when the service is performed in a hospital outpatient department, not in a physician office.

Service	Typical reason it’s on the list
Blepharoplasty	Can be cosmetic rather than functional
Botulinum toxin injections	Cosmetic vs. medical use
Panniculectomy	Cosmetic vs. medical use
Rhinoplasty	Cosmetic vs. functional
Vein ablation	Rapid growth in volume
Cervical fusion with disc removal	Rapid growth in volume
Implanted spinal neurostimulators	Rapid growth in volume
Facet joint interventions	Added July 2023

Source: CMS, Prior Authorization for Certain Hospital Outpatient Department Services.

Where Authorizations Go Wrong

Why Approved Authorizations Still End Up as Denied Claims

Getting the approval is only half the job. A large share of authorization-related denials happen on claims where an authorization was obtained — it just didn’t match what was billed.

The CPT code changed after the auth

A procedure authorized as one code but performed and billed as another — a different level, an added component, a different approach — will deny unless the authorization is updated, usually within a short window after the service.

Units or visits ran out

Therapy, injection series, and infusion authorizations approve a set number of units or visits. The visit after the last approved one denies, even when the care was necessary.

The auth expired before the date of service

Rescheduled surgeries and delayed imaging fall outside the approved date range. Extension requests have to go in before the window closes.

Wrong rendering provider or location

Authorizations are often tied to a specific provider and place of service. Moving a case from the hospital to an ASC, or to a colleague, can void it.

Retro-authorization deadlines missed

Some payers allow a retroactive authorization for urgent or emergency care, but only for a few days after the service. Missing that window turns a fixable gap into a write-off.

The wrong payer rule was cited

Quoting the 72-hour Medicare Advantage deadline to a self-funded employer plan, for example, goes nowhere. Every escalation should cite the rule that actually binds that plan.

Our Process

How MedVersify Handles Your Prior Authorizations

Map your auth-heavy services

We review which of your CPT codes and payers trigger authorization most often and build a payer-by-payer requirement sheet for your practice.

Check at scheduling

Every new booking for a mapped service is checked. If an auth is needed, the request is opened the same day.

Submit a complete request

Clinical documentation is assembled against the payer’s criteria before submission, so requests aren’t pended for missing records.

Follow up every day

Pending requests are checked daily and escalated when the payer’s decision deadline passes.

Appeal or peer-to-peer

Denials go to written appeal or a scheduled peer-to-peer, whichever is faster for that payer.

Match the auth to the claim

The auth number, codes, units, and dates are verified on the claim before it goes out, so an approved service gets paid.

FAQ

Frequently Asked Questions

What does a prior authorization service do?

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A prior authorization service takes over the work of getting payer approval before a service is performed: checking whether an authorization is required, submitting the request with supporting clinical documentation, following up until the payer decides, arranging peer-to-peer reviews, appealing denials, and making sure the approved authorization matches the claim that is billed.

How long does prior authorization take in 2026?

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For Medicare Advantage, Medicaid, and CHIP plans, the CMS-0057-F rule has required decisions within 72 hours for expedited requests and 7 calendar days for standard requests since January 1, 2026. Exchange plans on the federal marketplace are excluded from those new deadlines. Commercial plans set their own timelines through contracts and state law.

Does traditional Medicare require prior authorization?

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Only for a limited set of services: certain hospital outpatient department procedures such as blepharoplasty, vein ablation, and facet joint interventions; certain DMEPOS items; and, from 2026, a defined list of services in the six states running the WISeR model (Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington). See our WISeR guide.

Can you appeal a prior authorization denial for us?

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Yes. We prepare written appeals with the clinical record and the payer’s own coverage criteria, and we schedule peer-to-peer reviews when the payer offers them. Appeals are worth filing: KFF found 80.7% of appealed Medicare Advantage prior authorization denials in 2024 were overturned in whole or in part.

Can you handle prior authorization without doing our billing?

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Yes. Prior authorization is available as a standalone service. It works best alongside our medical billing service because the authorization can be matched to the claim automatically, but it doesn’t have to be.

What is a gold card program?

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A gold card program exempts providers with a consistently high prior authorization approval rate from submitting prior authorizations for certain services. Texas passed the first state gold-carding law in 2021, and several other states and some payers have since created their own programs. Tracking your approval rate by payer is how you prove you qualify.

Do prior authorizations need to be obtained for out-of-network care?

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Often yes, and the rules can be stricter. Out-of-network requests may need a network-adequacy or medical-necessity justification. We check the patient’s plan rules before the visit is scheduled.

Free Prior Authorization Assessment

Take Prior Authorization Off Your Staff’s Plate.

Tell us which services and payers create the most authorization work. We’ll show you how we’d handle them and what it would cost — no obligation.

Prefer to call? (507) 312-9282

Sources

Payer rules change often. Figures and deadlines on this page reflect the sources above as of the date they were published — confirm against your payer contract and current CMS guidance before relying on them for a specific claim.