Prior-authorization workflow
Treat each item as a handoff. “Ready” means you can point to the proof, not that someone said it was probably handled.
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- Owner
- Patient and ordering clinical office
- Proof to keep
- Medicine, service, or device name plus prescriber, site, and supplier when relevant
- Ready when
- Everyone is referring to the same request
- Next action
- Ask the plan which benefit processes it
- Owner
- Health plan
- Proof to keep
- Current policy or benefit document and official submission instructions
- Ready when
- The applicable rule and channel are identified
- Next action
- List every required field and document
- Owner
- Treating clinical office
- Proof to keep
- Patient-specific records required by the plan
- Ready when
- The clinician confirms the record is accurate and complete
- Next action
- Send through the authorized route
- Owner
- Plan and supplier, pharmacy, facility, or clinic
- Proof to keep
- Written network status and required product or billing details
- Ready when
- The supplying and billing entities are accepted for this request
- Next action
- Resolve any network or benefit mismatch
- Owner
- Party designated by the plan instructions
- Proof to keep
- Submitting entity, submission date, channel, and reference number
- Ready when
- One party has accepted responsibility for opening the request
- Next action
- Confirm receipt with the plan
- Owner
- Patient or authorized representative, with the plan
- Proof to keep
- Dated status, reference number, expected decision date, and applicable deadline
- Ready when
- The current state and next check-in are written down
- Next action
- Check again before, not after, the deadline
- Owner
- The party that owns the named missing item
- Proof to keep
- Plan notice naming what is missing plus proof of resubmission
- Ready when
- The plan confirms the item was received and attached
- Next action
- Ask whether the review clock or deadline changed
- Owner
- Patient or authorized representative, clinical office, and plan as their roles require
- Proof to keep
- Complete written approval or denial notice
- Ready when
- The reason, effective dates, review route, and deadline are understood
- Next action
- Act on the approval or build an appeal around the exact denial reason
What is prior authorization?
It’s your plan’s pre-service review of one specific request, done under its current rules. Authorization isn’t the same as a prescription, a medical recommendation, a price quote, or a guarantee that your final claim gets paid. Evidence Evidence
Why this item matters
- Sources cited, not yet graded
People I have heard from ask what prior authorization involves and whether they can afford what comes after it. I read the CMS order requirements and the Department of Labor page on plan information. Your request may need clinical information plus operational details - the item or service, prescriber, site, supplier, and benefit pathway. What’s required depends on your plan.
Check before moving on
- Depends on you
Your plan’s current rule and official submission route decide which fields and documents you need. Confirm both with your plan before you submit the request.
Questions for the clinical office, plan, or supplier
What exactly is being authorized?
Saving keeps this on your device and needs JavaScript, which is off in this browser.Which benefit and policy apply?
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What information may the clinical office need to organize?
Your clinical office may need a clear diagnosis and history, your treatment goal, relevant prior care, why this option is being considered, and findings specific to you. If a device is involved, they may also need an order plus supplier information. Evidence
Why this item matters
- Sources cited, not yet graded
I read Medicare’s equipment rules. They split paperwork into two kinds. Standard order details are the same for every patient. The other records describe your own medical situation. Other plans may ask for something different.
Check before moving on
- Depends on you
Your clinician should reach and certify any medical-necessity conclusion straight from your own record. Use your plan’s requirements to organize the real facts - don’t copy someone else’s letter.
Questions for the clinical office, plan, or supplier
Which clinical facts are missing?
Saving keeps this on your device and needs JavaScript, which is off in this browser.Which supplier or billing facts are missing?
Saving keeps this on your device and needs JavaScript, which is off in this browser.Who is responsible for each missing item?
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How do I know the request was actually submitted and reviewed?
Ask for the submission date, reference number, exact item or service requested, who submitted it, the current status, anything missing, and when you’ll hear back next. Keep the actual approval or denial notice - don’t rely on a phone summary. Evidence
Why this item matters
- Sources cited, not yet graded
I read the federal appeal guidance. Written notices and records matter most if a decision later needs correcting or appealing. Your plan should explain a denial and give you its review route.
Check before moving on
- Depends on you
A status call doesn’t extend your deadline. Timing rules vary, and whether you qualify for urgent review depends on your specific plan.
Questions for the clinical office, plan, or supplier
What is the current status?
Saving keeps this on your device and needs JavaScript, which is off in this browser.What information is still missing?
Saving keeps this on your device and needs JavaScript, which is off in this browser.What is the next deadline?
Saving keeps this on your device and needs JavaScript, which is off in this browser.
Who submits the request?
Confirm who’s actually submitting - don’t assume. Depending on your benefit and plan, the clinical office, pharmacy, facility, supplier, you, or another authorized representative might start or finish different parts of the request. Evidence Evidence
Why this item matters
- Sources cited, not yet graded
I checked how the CMS order rules split these roles. The person who recommends your treatment, the entity that bills, and the entity that supplies equipment can all be different people. A home-unit request can stall when each one expects someone else to send the order, clinical notes, product details, or billing information.
Check before moving on
- Depends on you
Your plan’s current instructions decide who may submit and which channel they have to use. Ask each party to name exactly what part they own and when they’ll act on it.
Questions for the clinical office, plan, or supplier
Who will open the request?
Saving keeps this on your device and needs JavaScript, which is off in this browser.Who sends clinical records?
Saving keeps this on your device and needs JavaScript, which is off in this browser.Who supplies item and billing details?
Saving keeps this on your device and needs JavaScript, which is off in this browser.
What should I write down during a status call?
Write down the date, phone number, person or department, and reference number. Add the exact request, current status, what’s missing, who owns the next action, the submission route, and your next check-in date. Read the summary back before you hang up. Evidence
Why this item matters
- Sources cited, not yet graded
I would keep one call sheet and reuse it every time. That makes it easier to compare answers and show your clinical office or supplier exactly what’s still incomplete. Hang onto the written approval or denial - a phone summary doesn’t replace it.
Check before moving on
- Depends on you
Your call notes are a record of the conversation, not a coverage decision. If an answer affects delivery or a large payment, get it in writing through your plan’s secure portal or another official channel.
Questions for the clinical office, plan, or supplier
What is missing?
Saving keeps this on your device and needs JavaScript, which is off in this browser.Who owns the next action?
Saving keeps this on your device and needs JavaScript, which is off in this browser.When should I check again?
Saving keeps this on your device and needs JavaScript, which is off in this browser.
Questions that can change the next decision
For your health planWhat exact request, benefit, current policy, submission route, and deadline apply?
Saving keeps this on your device and needs JavaScript, which is off in this browser.For the clinical officeWhich patient-specific records are required, who owns the submission, and when will it be sent?
Saving keeps this on your device and needs JavaScript, which is off in this browser.For the plan or supplierWhat is missing now, who owns the next action, and when will the written status or decision be available?
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Evidence behind this page
Sources
Each evidence badge opens the source and its limits. The full list stays available here.
- U.S. Department of Labor, Employee Benefits Security AdministrationRegulatory · Regulatory / guideline, tier 1Independent source
- Published
- SteadySkin last checked
What this source can and cannot tell you
What this source supports
Supports that participants in ERISA-covered plans receive or may request important plan documents, including the summary plan description, and that written requests can matter.
What it does not support
It does not apply identically to every coverage regime, interpret a specific plan, establish coverage for phototherapy, or provide legal advice.
Claim-specific review for this source is still in progress. Only the source-level evidence and limits are shown here.
- HealthCare.gov, U.S. Centers for Medicare & Medicaid ServicesRegulatory · Regulatory / guideline, tier 1Independent source
- Published
- SteadySkin last checked
What this source can and cannot tell you
What this source supports
Supports a general US individual and group health-plan distinction between internal appeal and eligible external review, and the need to use the denial notice for instructions.
What it does not support
Rights, deadlines, urgent pathways and external-review availability vary by plan and jurisdiction, so this source does not supply a universal deadline or guarantee review.
Claim-specific review for this source is still in progress. Only the source-level evidence and limits are shown here.
- U.S. Centers for Medicare & Medicaid ServicesRegulatory · Regulatory / guideline, tier 1Independent source
- Published
- SteadySkin last checked
What this source can and cannot tell you
What this source supports
Supports current Medicare context that DMEPOS orders use standardized elements and that supporting documentation is beneficiary-specific.
What it does not support
It does not establish that a home phototherapy device is covered, identify a code, apply to commercial plans, or replace the current plan and supplier requirements.
Claim-specific review for this source is still in progress. Only the source-level evidence and limits are shown here.