What Is Prior Authorization in
Medical Billing?
Prior authorization (PA) refers to the process that allows a provider to request authorization from a patient's health plan before providing that patient with a service, prescription, diagnostic test, or procedure that can be reasonably expected to be covered by the plan. It is a learning cost containment strategy used by payers to validate medical necessity and benefit coverage.
In almost all cases, the prior-authorization process consists of the following steps:
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Provider submits documentation to payer
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The provider verifies that the documentation coincides with the payer's documentation specifications.
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The provider follows up if there are approvals/subsequent clarifications needed.
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The provider either submits a restoration request to the payer or files an appeal to their history of denial by the payer.
If the provider does not finish the prior-authorization process, the insurer may deny payment after the service has been provided, leaving the provider or the provider as well as the patient to be responsible for the cost.
What We Offer:
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Committed Prior Authorization Experts
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Templates for documentation that must be submitted promptly
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Monitoring authorization approval
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Instantaneous communication with your employees
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Analytics and reports on the status of requests every week
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Process management tailored to the payer
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On-demand assistance for urgent situations
What makes our prior authorization service different
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To hasten the approval of requests, we create payer-ready brief clinical narratives and evidence using clinical-first packets.
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End-to-end management: appeals, starting, submittal, payer follow-up, and peer-to-peer escalation.
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Automated checks, ePA integration, and smart routing speed help to combine technology with humans; clinicians and authorization specialists use judgment calls.
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Faster patient access: get permissions earlier in the workflow to help to lower postponed or cancelled operations.
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Patient- and provider-facing updates with unambiguous next steps and deadlines define transparent status tracking.
What Services Typically Require Prior Authorization?
Most payers require PAs to provide specialized or costly services, like:
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Advanced diagnostic imaging (MRI, CT scans, PET)
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Surgeries (orthopedic, bariatric, spinal, etc.)
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Specialty medications and biologics
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Physical therapy, chiropractic care, and rehab
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Behavioral health services
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DME and orthotics
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Pain management and injections
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Out-of-network services
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Telehealth across state lines
Because they understand the subtle differences between payers, specialties, and patient conditions, our staff makes sure that nothing is overlooked.
Our Prior Authorization Services
1. Intake & eligibility check
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Verify patient coverage and determine if the treatment or service needs previous approval.
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Check subscriber information, benefit caps, and any pre-cert needs influencing permission.
2. Clinical packet preparation (the part that matters)
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Pull the minimum but complete documentation payers want: relevant progress notes, imaging reports, labs, prior conservative treatment documentation, and procedure rationale.
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Turn clinical data into brief, payer-focused summaries that clearly define clinical need.
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Include map evidence to payer criteria as well as references for guidelines when pertinent.
3. Electronic Prior Authorization (ePA) & portal submission
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If available, submit through payer portals, clearinghouses, or ePA connections.
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Where supported, utilize structured forms and attachments to cut down on human processing time.
4. Payer follow-up & escalation
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Log calls, record representative names/confirmation numbers, and revise schedules on unresolved requests by proactive follow-up.
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When first findings are unfavorable or late, move on to peer-to-peer reviews and clinical liaisons.
5. Peer-to-peer coordination & clinical support
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Arrange physician-to-physician dialogues when clinical subtlety might affect approval.
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For effective peer chats, get ready talking points and clinical summaries.
6. Appeals & retrospective requests
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Create appeal packets with obvious counterarguments and supporting clinical data.
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If payer policy permits, submit and trace appeals; seek retrospective reviews.
7. Real-time status dashboards & patient communications
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Give clinician- and patient-facing approved, denied, or pending status updates with expected timelines and next actions.
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Appointment at-risk flags and trigger scheduling include contingency plans.
8. Reporting, analytics & continuous improvement
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First-pass approval rate, reason for denials, payer-level trends, and track authorization turnaround time.
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Use insights to address upstream documentation deficiencies and lower future denials.
Why Prior Authorization Services
Are Critical
Depending on the payer, specialty, and what is being asked for, authorizations can take between hours and days. Most staff/processors on staff do not have the time or expertise to do a good job with this. Therefore, they will either make errors or omissions or misunderstand payer rules, and each will have a repeatable narrative with the same nonsensical issues:
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Delayed patient care
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Denied claims and uncovered services
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Frustrated providers or staff
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Sunk revenue and scheduled care
As payer rules and automation change, outsourcing of authorizations becomes a best practice for practices that intend to grow.
Why Choose Sirius Solutions Global?
We stand out as a reliable partner in prior authorizations because of the following:
Total Process Management
We take care of everything, from confirming eligibility to granting final approval.
Proficiency
We are aware that different specialties have different authorization requirements.
Payer Understanding in Each State
Our staff members are knowledgeable about Medicare Advantage, Medicaid, and commercial payers.
Updates on status in real time
We use secure status tracking to keep your team updated at every stage.
Quicker Reaction Times
In order to help avoid rescheduling or lost revenue, we expedite approvals.
Support for Appeal and Resubmission
We provide prompt and accurate responses to appeals in the event that a request is denied.
Workflow Compliant with HIPAA
All correspondence, documentation, and data processing are private and secure.
How our AI and automation help
Automation removes repetitive work and surfaces the cases that need human judgment:
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Smart packet builder: pulls the most relevant notes and documents for a given authorization type so clinicians don’t have to search.
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Template suggestion engine: proposes payer-specific justification language that a clinician can review and sign.
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Auto-fill & ePA connectors: pre-populate forms and submit via payer portals or ePA standards to save time.
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Denial prediction: flags requests with high denial risk so we can add extra evidence or route to a senior clinician.
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Workflow routing: automatically assigns authorizations to the right specialist or escalation path based on complexity and payer.
We never allow automation to act unchecked on clinical decisions — clinicians and credentialed specialists review and sign off before submission.
Why prioritize prior authorizations?
Prior authorizations touch revenue, operations, and patient experience:
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Unapproved services cause last-minute cancellations, unhappy patients, and lost revenue.
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Incomplete clinical documentation is the most common cause of denials or long hold times.
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Manual follow-up is time-consuming and often inconsistent across staff shifts.
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A proactive authorization workflow increases first-pass approvals and reduces appeals.
Fixing prior auths means fewer bottlenecks — patients get care on time and your revenue stays steady.
What makes our prior authorization service different
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Clinical-first packets — we prepare concise, payer-ready clinical narratives and evidence so requests get approved faster.
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End-to-end management — initiation, submission, payer follow-up, peer-to-peer escalation, and appeals.
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Technology + humans — automated checks, ePA integration, and smart routing speed work; clinicians and authorization specialists make judgment calls.
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Faster patient access — reduce cancelled or delayed procedures by getting approvals earlier in the workflow.
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Transparent status tracking — patient- and provider-facing updates with clear next steps and timelines.
Prior authorizations shouldn’t be a paperwork trap that slows care and bleeds revenue. At Sirius Solutions Global we take the administrative weight off your team by managing prior auths end-to-end: clinical documentation packages, payer submission, follow-up, ePA support, and escalation — all supported by automation and always supervised by clinicians and credentialed specialists.
Business Impact of Prior Authorization Optimization
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Protect thousands of dollars in potential lost reimbursements
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Reduce wait time for services by up to 48–72 hours
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Cut down claim denials due to missing authorizations by over 70%
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Prevent unnecessary patient rescheduling and cancellations
Get Prior Authorizations Approved Without the Headache
Prior authorizations shouldn't interfere with your workflow or prevent you from providing care. Let Sirius Solutions Global take that load off your team; we'll ensure that each request is submitted, looked into, and approved in a timely and accurate manner. Now is the time to schedule a free consultation. So that you can focus on patient care, let's remove the barriers.