Prior authorisation & referrals · Medical practices & clinics
Authorise care before it gets delivered.
PA requests stall in the radiology benefit manager's portal while fax-back denials sit unread. A peer-to-peer window closes and the procedure gets rescheduled.
The reality
Prior auth is a waiting game.
An MRI of the brain gets ordered, the PA goes into eviCore or Carelon — the radiology benefit manager the payer routes high-tech imaging through — and then nothing. The status sits at pending, the conservative-care history the RBM wanted never got attached, and a denial arrives by fax that no one opens until the patient calls asking why the appointment moved.
The operator owns the PA lifecycle. It submits with the right CPT and the clinical documentation the RBM criteria require, watches the portal and fax queue for status, escalates denials to peer-to-peer, and files the appeal with the medical-necessity record — so care is authorised before it is scheduled.
How the operator runs prior authorisation & referrals
Auth PA-31188 · Submission
submitting- CPT 70553 and ICD matched to eviCore criteria
- Symptom history and clinical notes attached
- Submitted to RBM portal
01Submit with documentation
Files the PA with the ordered CPT, diagnosis, and the symptom history and conservative-care notes the RBM criteria require up front.
Auth PA-31188 · Tracking
tracking- Authorisation number captured
- Pending 48h — RBM line called
- Status check — in review
02Track and chase status
Monitors the RBM portal and fax-back queue, logs the authorisation number, and chases anything stuck past the two-business-day decision window.
Auth PA-31188 · Denial
appealing- Denial reason: criteria not met
- Peer-to-peer slot scheduled
- Appeal packet — assembling
03Escalate denials
Routes denials to peer-to-peer with the provider, or files the appeal citing the RBM's medical-necessity criteria.
The outcome
−70% of PA work off the team
Authorise care before it is delivered.
- Requests submitted complete, so fewer bounce back for missing symptom history or conservative-care notes
- Pending auths chased against the RBM's two-business-day window instead of forgotten in a portal
- Denials hit peer-to-peer before the procedure date slips
Common questions
Prior authorisation & referrals
- What does the Prior authorisation & referrals operator do?
- The operator owns the PA lifecycle. It submits with the right CPT and the clinical documentation the RBM criteria require, watches the portal and fax queue for status, escalates denials to peer-to-peer, and files the appeal with the medical-necessity record — so care is authorised before it is scheduled.
- What impact does the Prior authorisation & referrals operator have?
- −70% of PA work off the team. Authorise care before it is delivered.
- How does the Prior authorisation & referrals operator work?
- Files the PA with the ordered CPT, diagnosis, and the symptom history and conservative-care notes the RBM criteria require up front. Monitors the RBM portal and fax-back queue, logs the authorisation number, and chases anything stuck past the two-business-day decision window. Routes denials to peer-to-peer with the provider, or files the appeal citing the RBM's medical-necessity criteria.
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