Prior authorization services
Prior authorization built around the documentation payers actually require
A prior authorization denial isn’t usually a clinical disagreement. It’s a request that went out without the note the payer needed, to the wrong form, or late enough that the procedure happened first.
House of RCM assembles the clinical support before the request goes out, submits it the way that specific payer requires, and tracks every request to a decision rather than to a submission confirmation. Your clinical staff stops sitting on hold.
Included at 3% of collectionsOr priced per requestTracked to a decision
Free auth review
Four fields. HIPAA compliant, and never shared.
- 5+ years in business
- 25+ specialties
- All 50 states
- US-based authorization team
- HIPAA compliant, BAA signed first
What practices get with House of RCM
The numbers behind our service, from claim submission to support.
Clean claims on submission
Increase in claims
Billing submitted
Fastest electronic claim turnaround
US-based support
HIPAA compliant
A review looks at your auth-related denials and shows how many were preventable at submission.
Prior authorization denials are mostly process failures
A payer refusing a procedure on clinical grounds is a real disagreement with a real appeal path. That’s the minority. Most authorization denials are the request itself: incomplete, late, sent to the wrong place, or approved and then expired before anyone scheduled the service.
Those are the expensive ones, because the care usually happened anyway. The provider treated the patient and the claim denies for an authorization problem nobody was watching.
Documentation too thin
The request met the form’s requirements but not the payer’s medical necessity criteria, which are a different and longer list.
Submitted too late
The request went out after the service was already scheduled, leaving no room for a decision, let alone an appeal.
Wrong channel or form
Portal when the payer wants fax, or the general form when the procedure has its own. It doesn’t bounce, it just sits.
Approved, then expired
An authorization with an end date nobody tracked. The service happens a week late and the approval no longer covers it.
Approved for the wrong thing
Different code, different site of service, or fewer units than were delivered. Technically approved, functionally denied.
We’ll categorize your auth denials and show which of these is generating them.
What is prior authorization?
Prior authorization is a payer’s requirement that certain services be approved before they’re delivered. The practice submits the proposed service with clinical documentation, the payer reviews it against its own medical necessity criteria, and the service is approved, denied, or approved with conditions such as a unit count or a date range.
The requirement is not clinical judgment and it isn’t optional. A service delivered without a required authorization is usually not payable, however medically necessary it was, and in many plans there’s no remedy after the fact.
What makes it operationally hard is that the requirement varies by payer, by plan within that payer, by procedure, and by site of service. The same procedure can need authorization under one plan and not another from the same insurer, which is why checking is the job rather than remembering.
Not sure which of your services actually require authorization? That’s the first thing a review establishes.
Every stage of a request, handled by one team
Included in the 3% billing rate rather than sold as an add-on, because an authorization is part of whether a claim was ever collectable.
Requirement check
Whether this service, for this plan, at this site of service, actually needs authorization. Checked rather than assumed in either direction.
Criteria review
The payer’s medical necessity criteria pulled before anything is written, so the request is built to what they’ll measure it against.
Documentation assembly
Chart notes, imaging, conservative treatment history, and test results gathered into a packet that answers the criteria point by point.
Submission
Filed promptly through whatever channel that payer requires, with the confirmation and reference number recorded.
Tracking to a decision
Followed until approved or denied, not until submitted. A request with no decision is an open risk, not a completed task.
Expiration monitoring
Approval dates and unit counts tracked against the scheduled service, so an authorization doesn’t lapse between approval and delivery.
Appeals and peer-to-peer
Denials appealed with the criteria cited and the gap closed. Where a peer-to-peer is required, we schedule it and brief your provider.
Reporting
Approval rate, turnaround, and denial reasons by payer, so you can see which payers are genuinely slow and which requests keep failing.
All eight stages are included at 3%. There’s no per-request fee for billing clients.
The form is the easy part. The documentation decides it.
Anyone can complete an authorization form. What determines the answer is whether the clinical packet addresses the specific criteria that payer uses for that procedure, in the order a reviewer reads them.
Most denied requests were complete. They just didn’t say the thing the reviewer was looking for, usually because nobody read the criteria before writing the request.
When the documentation genuinely doesn’t support the criteria, we tell you that instead of submitting and waiting three weeks for a no. Sometimes the answer is a conservative treatment trial first, and knowing that early is worth more than an appeal later.
| Criterion | What has to be in the packet |
|---|---|
| Diagnosis supports the service | Documented findings, not just a code on a form |
| Conservative treatment tried | What was tried, for how long, and the outcome |
| Objective evidence | Imaging, test results, or measured functional deficit |
| Service is the appropriate next step | Clinical reasoning tied to the findings above |
| Site of service is appropriate | Why office, facility, or inpatient, where the payer distinguishes |
A request that answers all five is usually approved on the first submission. A request missing one is usually denied for that one.
Send us a denied authorization and we’ll tell you which criterion the packet didn’t answer.
What an approval does and doesn't guarantee
An approved authorization means the payer agreed the service is medically necessary under the plan. It doesn’t mean the claim will pay. Eligibility can change, the service delivered can differ from the one approved, and an approval carries dates and unit limits that the claim has to fall inside.
We’d rather say that here than after your first surprise. What authorization does is remove the preventable share of denials, which is most of them. What it can’t do is make a claim unconditional.
Where approvals still fail, and what we do
The approval expires before the service happens. We track end dates against your schedule and request an extension before it lapses.
The service delivered differs from the one approved, by code, units, or site of service. Flagged at posting and traced, so the pattern gets fixed rather than repeated.
The patient’s coverage changed between approval and service. Caught by verification, which runs on the same schedule.
The payer has no record of an approval it issued. This is why every request is logged with a reference number and the name of who confirmed it.
Had a claim deny despite an approved authorization? Send it over and we’ll tell you if it’s appealable.
Two ways to buy prior authorization
If we handle your billing, authorization is part of it. If you want only the authorization work while your billing stays where it is, that’s priced per request.
of collections, authorization included
For practices where House of RCM handles the full billing operation.
- Requirement check on every scheduled service
- Criteria review and documentation assembly
- Submission through each payer's required channel
- Tracked to a decision, not to a confirmation
- Expiration and unit monitoring
- Appeals, with peer-to-peer scheduled and briefed
- Eligibility, coding, submission, denials, and AR
No setup fee. No per-request charge. No long-term contract.
quoted before any work starts
Standalone authorization work, with no change to who does your billing.
- Same process as the included service
- Priced per request submitted, not per approval
- Results and reference numbers posted in your system
- No setup fee, no minimum volume, cancel anytime
Priced per request rather than per approval on purpose. A vendor paid only on approvals has a reason to avoid the hard ones, and the hard ones are why you’d hire anybody.
What authorization work costs you in staff time
Use your own figures. Most practices have never totalled this.
Estimate only, from figures you enter. If a nurse or clinical staff member is doing this work, use their rate, not an administrative one.
Send your monthly request volume and we’ll give you the per-request total before any work starts.
Authorization in-house versus a dedicated team
In most practices this work sits with clinical staff, because the documentation requires clinical judgment to assemble. That’s also why it’s the most expensive hour in the building to spend on hold.
| Metric | In-house | House of RCM |
|---|---|---|
| Who does it | Often a nurse or clinical assistant, between patients | A team that does only this |
| Cost | Staff time every month | Included at 3%, or priced per request |
| Criteria research | Rarely. The form gets completed and sent | Criteria pulled before the request is written |
| Tracking | Until submitted, then it depends who remembers | Until a decision is recorded |
| Expiration monitoring | Uncommon, and this is where approvals get lost | Tracked against your schedule |
| Appeals | Often skipped. The procedure already happened | Filed with the criteria cited |
| Coverage during absence | Requests queue until that person returns | Team coverage, no gap |
If you have someone who owns authorization and works ahead of the schedule, keep them. The case for handing it over is strongest when the person doing it is clinical, because that’s the hour with the highest alternative use in your practice.
Tell us who handles authorization now and we’ll say plainly whether this is worth changing.
How a request is worked, start to decision
It runs off your schedule rather than off requests from your staff, which is the difference between a system and someone remembering.
Stage 1 · at scheduling
Requirement identified
Whether the service needs authorization under that specific plan, checked as soon as it’s on the calendar rather than the week before.
Stage 2 · same day
Criteria and documentation
The payer’s criteria pulled, then the clinical packet assembled to answer each one. Gaps come back to you before submission.
Stage 3 · on receipt
Submitted and logged
Filed through that payer’s required channel, with the reference number and confirmation recorded in your system.
Stage 4 · until decided
Followed to a decision
Chased until approved or denied. A request sitting with no decision is tracked as an open risk against a scheduled service.
Stage 5 · after approval
Monitored to the service date
Dates and units watched against your schedule, with an extension requested before an approval lapses.
Stage one starts with the authorizations you already have pending.
Authorization burden by specialty
Some practices submit a handful of requests a month. For these, authorization is a standing operational cost and the main reason procedures get delayed.
Pain management
Injections, blocks, and ablations, where criteria usually require documented conservative treatment and a specific interval between procedures.
Orthopedics
Surgical authorization with imaging and conservative care history, plus durable equipment that carries its own requirement.
Imaging and diagnostics
Advanced imaging almost universally requires authorization, and the referring provider’s request is the one the payer reviews.
Behavioral health
Session authorizations that renew mid-course, where a lapse stops treatment rather than just delaying a claim.
Therapy services
Visit authorizations with unit counts, where exceeding the approved number is the most common unpaid-visit cause.
Rheumatology and infusion
Biologics with step-therapy requirements, where the packet has to document what was tried and failed first.
Gastroenterology
Procedures where the screening versus diagnostic distinction changes both the authorization and the patient’s cost share.
Cardiology
Advanced imaging and procedures with appropriate-use criteria that the request has to address directly.
Tell us your specialty and we’ll name the criteria your payers apply most often.
We work in your system and your payers' systems
Authorization numbers, approval dates, and unit counts post in your system where scheduling and billing both see them. An approval that lives in a vendor’s portal is an approval your front desk can’t act on.
Payers still differ enormously in how they accept requests. Some have a working portal, some want a specific fax form, and some require a phone call for certain procedures. We use whichever that payer actually processes rather than whichever is easiest.
Using a specialty PM system or an auth portal of your own? Bring it to the first call.
Your clinical records, protected
Authorization is one of the most clinically detailed parts of the revenue cycle, because the packet is clinical documentation by definition. We sign a Business Associate Agreement before anyone opens a chart.
BAA signed first
Executed before access is granted, not after work starts.
Minimum necessary
The packet carries what the criteria require. Unrelated history in the chart stays out of it.
Role-based access
Each team member reaches only the records their assignment requires. Access is logged and reviewed.
Documented submissions
Every request logged with payer, date, channel, reference number, and contents, which is what an appeal rests on.
We sign the BAA before anyone opens a chart. Ask to see it first if you’d rather.
Client results
What practices say about their authorizations
Reviews from practices whose authorization work House of RCM handles. Each one can be opened on the platform it came from.
★★★★★
“Jane is simply amazing. My business would not be nearly as successful if it was not for her. She is always one step ahead of the game, knows all the in’s, out’s, and tricks of billing. She is the best business decision I ever made!!”
House of RCM client
★★★★★
“Danielle, Jane, and their staff are professional and efficient in all aspects of billing, medical claims, and all insurances. They offer superior customer service and always answer our questions promptly. We receive weekly updates that keep us informed of how our medical claims are processing. I would highly recommend House Of RCM!”
House of RCM client
Want to speak with a practice in your specialty before deciding? We’ll connect you.
FAQ
Questions practices ask about prior authorization
Question not covered here? A specialist will answer it on a call, no sales script.
What is prior authorization?
It’s a payer’s requirement that certain services be approved before they’re delivered. The practice submits the proposed service with clinical documentation, the payer reviews it against its medical necessity criteria, and the service is approved, denied, or approved with conditions such as a unit count or a date range.
How much do prior authorization services cost?
Two options. Included in the 3% of collections where House of RCM handles your billing, or priced per request standalone, quoted up front, with no minimum volume and no setup fee.
Why is it priced per request rather than per approval?
Because a vendor paid only on approvals has a reason to avoid the difficult ones, and the difficult ones are why you’d hire anybody. Per request keeps the incentive on working every case properly.
Does an approved authorization guarantee the claim will pay?
No. An approval means the payer agreed the service is medically necessary under the plan. The claim still has to fall inside the approved dates, codes, units, and site of service, and the patient’s eligibility has to hold. Verification runs alongside authorization for that reason.
What happens when a request is denied?
We identify which criterion the packet didn’t satisfy, close that gap if the record supports it, and appeal. Where the payer requires a peer-to-peer review, we schedule it and brief your provider on what the reviewer will ask.
Can you do the peer-to-peer for us?
No, and nobody can. A peer-to-peer is a clinical conversation between your provider and the payer’s reviewer. What we do is schedule it, prepare the case, and tell your provider which criteria the reviewer is working from.
How do you know which services need authorization?
We check per plan rather than relying on a general list. The same procedure can require authorization under one plan and not another from the same insurer, and that varies by site of service too.
Do you track authorizations after approval?
Yes, and this is where most approvals get lost. Approval dates and unit counts are tracked against your schedule, with an extension requested before an authorization lapses rather than after the service happens.
What if the documentation doesn't support the criteria?
You’ll hear that before we submit, not three weeks later. Sometimes the right answer is a documented conservative treatment trial first, and knowing that early is worth more than an appeal afterward.
How quickly do you submit a request?
As soon as we have the clinical documentation. The limiting factor is usually the record, not the submission, which is why requirement checks happen at scheduling rather than the week of the procedure.
Can we use this without moving our billing?
Yes. The per-request option exists for that. Your current billing stays where it is and we handle the authorization work only.
Does this work with our EHR?
Yes. Authorization numbers, approval dates, and unit counts post in your system where scheduling and billing both see them, rather than in a portal only we can open.
Find out what your authorization process is costing
A review looks at your auth-related denials, how many were preventable at submission, how many approvals expired before the service, and what the work is costing in staff hours. You keep the findings whether or not you work with us.
Bring a few months of denial data and a sense of who currently does this work. If it’s a nurse, that number usually settles the question on its own.
Included at 3%Or priced per requestHIPAA compliant
Request your free auth review
HIPAA compliant. Your information is never shared.