Orthopedic practices
Authorization for imaging, injections, physical therapy, surgical procedures, durable medical equipment, and other services. We help organize these requests and track them through the payer response.
Prior authorization services
Prior Authorization Services for Nevada Healthcare Providers
From authorization requirement checks and clinical documentation to payer submissions, status tracking, follow up, and denial support, Nevada Med Billing helps your team keep authorization requests moving.
Let Nevada Med Billing handle the payer approval process for your practice.
Requirement checks before schedulingPayer policy reviewExpedited and retro authorization supportStatus tracking until determinationAuthorization tied back to billingRequirement checks before schedulingPayer policy reviewExpedited and retro authorization supportStatus tracking until determinationAuthorization tied back to billing
Where it breaksThe authorization problem starts
The authorization problem starts
before the authorization request
Prior authorization problems rarely begin with the payer's final decision. They often begin earlier.
A service gets scheduled without checking the requirement. The payer is identified incorrectly. Clinical documentation is incomplete. A request is submitted through the wrong channel. Nobody checks the status for several days. An approval arrives but the approved service or date does not match the scheduled procedure. Each issue creates another administrative task.
Your staff may be spending time on work that does not generate a claim
01Checking whether authorization is required
02Finding the correct payer policy
03Confirming the patient's coverage
04Identifying the correct authorization channel
05Collecting clinical documentation
06Preparing the request
07Uploading medical records
08Responding to payer questions
09Calling payer representatives
10Checking pending requests
11Recording approval information
12Monitoring authorization dates
13Tracking approved units or visits
14Communicating authorization status to scheduling
15Resolving authorization related denials
Nevada Med Billing can take on this administrative workload according to your practice's established process.
The cost of a missWhat happens when prior
What happens when prior
authorization is missed?
A missed authorization can create different problems depending on the payer, plan, service, and contract.
The appointment may need to be rescheduled
When approval is required before a service can proceed, an unresolved request can interfere with scheduling.
The provider may face a claim problem
A claim can be denied when the payer determines that required authorization was not obtained or that the authorization information does not support the billed service.
Staff have to investigate after the service
Instead of resolving the issue before treatment, the billing team may have to research the payer's decision, contact the payer, gather records, correct information, or pursue an appeal.
Patient communication becomes harder
When an authorization issue appears after the encounter, the practice may need to explain why the claim did not process as expected.
The exact financial and administrative consequences depend on the payer and the applicable provider agreement.
Our servicesPrior authorization services
Prior authorization services
from Nevada Med Billing
Nevada Med Billing can support the authorization lifecycle from requirement checking through final documentation.
Authorization requirement research
We check available payer information to determine whether the planned service may require authorization, evaluated against the actual payer, plan, service, diagnosis, provider, and other applicable factors.
Payer policy review
Different health plans can apply different authorization rules. We review available payer guidance and identify the process that applies to the request.
Clinical documentation preparation
We help organize the clinical information required by the payer — physician notes, diagnosis information, treatment history, imaging reports, laboratory findings, previous treatment, and other supporting records.
Prior authorization submission
We prepare and submit authorization requests through the applicable payer channel, including portals and electronic authorization workflows where available.
Authorization status monitoring
A submitted request is not necessarily an approved request. We monitor pending cases and identify requests that require additional action.
Payer follow up
When the payer requests additional documentation or clarification, we help move the request to the next stage instead of leaving it unresolved.
Authorization approval documentation
When authorization is approved, we record the authorization reference, effective dates, approved service, units or visits, and other payer supplied information for the appropriate practice teams.
Authorization expiration tracking
Some authorizations apply only to a defined period or number of services. Tracking those limits helps your team identify when another request may be necessary.
Request anatomyA prior authorization request
A prior authorization request
needs the right information
A strong request is built around the payer's requirements and the clinical record.
Patient information
Accurate patient and insurance information helps prevent avoidable processing problems.
Provider information
The request may require information about the ordering or rendering provider, group, location, or facility.
Diagnosis information
The documented diagnosis helps establish the clinical context for the requested service.
Procedure or service information
The requested procedure, treatment, imaging study, medication, equipment, or therapy service needs to be identified accurately.
Clinical evidence
The payer may request medical records or other evidence supporting the requested service.
Previous treatment
For some services, the payer may ask about previous treatment, conservative therapy, medication trials, or other clinical history.
Supporting reports
Imaging, laboratory results, pathology, consultation notes, and other records may be relevant depending on the request.
Nevada Med Billing does not replace the provider's clinical judgment. Our role is to organize and manage the administrative authorization process using information supplied by the healthcare organization.
High complexity servicesPrior authorization for high volume
Prior authorization for high volume
and high complexity services
Authorization requirements become especially important when a practice performs services that frequently involve payer review.
MRI and CT authorization
Advanced diagnostic imaging can involve payer specific authorization requirements. We help identify the requirement and organize the information needed for the request.
Surgical authorization
Surgical services may require documentation supporting the procedure, diagnosis, previous treatment, and other payer specified information.
Physical therapy authorization
Therapy practices may need to track referrals, authorization periods, approved visits, visit limits, and renewal requirements.
Specialty drug authorization
Certain medications can require extensive payer review and supporting clinical documentation.
Infusion authorization
Infusion services may involve authorization for the medication, treatment plan, administration service, or related components.
Durable medical equipment authorization
Some equipment and supplies require documentation demonstrating the patient's clinical need and meeting payer specific criteria.
Behavioral health authorization
Certain behavioral health services can involve authorization requirements that vary by payer and plan.
Urgent and emergency authorization
When a procedure is scheduled within 24 to 48 hours, we flag the request as urgent, submit through the payer's expedited review track, and follow up as often as the payer's process allows. For true emergencies, we assess retro authorization eligibility immediately and submit the same day wherever the payer permits it.
Specialty supportSpecialty specific prior
Specialty specific prior
authorization support
Supporting documentationWhat documentation may support
What documentation may support
an authorization request?
Depending on the service and payer, supporting information may include:
Relevant clinical notes
Diagnosis information
Symptoms and clinical findings
Previous treatment
Medication history
Imaging results
Laboratory results
Treatment response
Referral information
Procedure details
Treatment plans
Other payer requested records
The exact requirements depend on the payer and service.
Additional information requestsWhat happens when the payer
What happens when the payer
requests more information?
Additional information requests should not be treated as a dead end.
Nevada Med Billing can review the payer request, identify what information is being requested, coordinate with the appropriate practice team, submit available supporting records, and continue tracking the request.
Without these details, pending authorizations can become difficult to manage as volume increases.
A request should have:
- A status
- A next action
- A responsible team member
- A follow up date
- A documented payer response
Denial workflowPrior authorization denials
Prior authorization denials
need their own workflow
A denial is different from a pending request. The first step is to identify why the payer denied the authorization. Possible reasons can include:
01Missing documentation
02Insufficient clinical information
03Service not meeting the payer's stated criteria
04Incorrect patient information
05Incorrect payer information
06Service information mismatch
07Benefit limitations
08Authorization submitted through an incorrect process
09Required previous treatment not documented
10Request submitted outside the applicable timeframe
The appropriate response depends on the payer and denial reason. Nevada Med Billing can help organize the administrative response, identify missing information, and route the case through the applicable reconsideration or appeal process.
Nevada payersMedicaid and commercial
Medicaid and commercial
authorization support
Nevada Medicaid prior authorization support
Nevada Medicaid provides provider resources for eligibility, claims, payments, and prior authorization through its Provider Web Portal. The program also publishes prior authorization reference information and service specific guidance for providers.
Nevada Medicaid's current provider resources should be used to determine the authorization requirements applicable to a particular service.
Nevada Med Billing can help Nevada practices incorporate Medicaid authorization checks and follow up into their existing revenue cycle workflow.
Commercial insurance prior authorization
Commercial plans can have their own authorization requirements, submission processes, clinical criteria, and documentation rules.
That means your staff should not rely on one universal authorization checklist.
A better process asks five questions
Which payer is responsible?
What exact service is being requested?
Does this plan require authorization?
What information does this payer require?
What happens after submission?
Nevada Med Billing builds these questions into the authorization workflow.
TechnologyThe technology behind
The technology behind
authorization management
Prior authorization work often involves more than one system. Your practice may use:
EHR
Practice management software
Payer portals
Electronic authorization tools
Document management systems
Secure communication systems
Scheduling software
Billing software
EpicCernerAthenahealtheClinicalWorksAdvancedMDTebraDrChronoNextGen HealthcareModMedCureMDWebPT
Nevada Med Billing can work within the technology environment already used by your organization rather than forcing your team into a completely different workflow.
ReportingWhat should your authorization
What should your authorization
dashboard show?
A practice should be able to see more than a list of submitted requests. Useful authorization reporting can include:
| Metric | What it tells your practice |
|---|---|
| Pending authorizations | How many requests still need action |
| Average authorization turnaround | How long requests remain unresolved |
| Authorization denial rate | How often requests receive an unfavorable decision |
| Additional information requests | How often payers ask for more documentation |
| Expiring authorizations | Which approvals need attention |
| Approved units or visits | How much authorized service remains |
| Authorization related claim denials | Whether authorization problems are reaching billing |
| Payer specific issues | Which plans create recurring administrative problems |
These metrics help management see where the authorization process is creating workload or revenue cycle risk.
Administrative burdenWhat CMS says about prior
What CMS says about prior
authorization workload
The administrative burden associated with prior authorization has been documented by federal healthcare policy research.
CMS cites estimates that providers can spend approximately 13 hours per week handling prior authorization related administrative work. CMS also cites estimated annual administrative costs of approximately $34,000 and 700 hours per provider. These are estimates cited by CMS, not a guaranteed cost for an individual practice.
For a practice with several providers, recurring authorization work can therefore represent a significant administrative commitment.
Nevada Med Billing can help practices determine which portions of that workload can be assigned to an experienced billing and authorization team.
13
Estimated hours per week on authorization work
$34K
Estimated annual administrative cost per provider
700
Estimated annual hours per provider
Why practices choose usWhy practices choose
Why practices choose
Nevada Med Billing
We take ownership of the administrative work
Your staff should know who is responsible for each pending request. We provide a defined process for checking requirements, preparing requests, submitting information, monitoring status, and documenting outcomes.
We work with your existing team
Some practices want to outsource the entire authorization process. Others want support only for high volume specialties or difficult requests. Our workflow can be structured around the level of support your organization needs.
We track more than submissions
A submitted request is only one event. We pay attention to pending cases, payer responses, additional information requests, approvals, denials, and expiration dates.
We connect authorization with billing
The authorization record should be useful after the service is performed. Connecting authorization information with billing helps your team investigate authorization related claim issues more efficiently.
Is it time?Is it time to outsource
Is it time to outsource
prior authorization?
Prior authorization outsourcing can make sense when the administrative workload has grown beyond what your internal staff can comfortably manage. It can also help when:
Authorization requests are increasing
Multiple payers have different processes
Physicians are spending time on authorization paperwork
Staff frequently call payers for status updates
Authorization denials are recurring
Requests are difficult to track
Your practice has multiple specialty services
Authorization information is not reaching billing
Expired approvals are creating problems
Your team needs dedicated authorization support
Nevada Med Billing can review your current process before you decide how much work to outsource.
Prior authorization FAQs
Frequently asked questions
Can't find what you need? Our Nevada team answers every question before you commit.
Prior authorization services help healthcare organizations manage the administrative process of obtaining payer approval for services that require authorization. The work can include requirement checks, documentation collection, request submission, status monitoring, payer follow up, approval tracking, and denial support.
Our team can help determine authorization requirements using available payer and plan information. Requirements can vary by payer, plan, service, diagnosis, provider, and location, so each request should be evaluated individually.
We track submitted requests and identify cases that require additional information or payer follow up. The specific tracking and escalation process can be configured around the practice's workflow.
We can help identify the stated denial reason, organize available supporting information, and assist with the administrative process for reconsideration or appeal when appropriate. Clinical decisions and provider supplied documentation remain the responsibility of the healthcare organization.
Nevada Med Billing can support administrative prior authorization workflows for Nevada Medicaid providers. Nevada Medicaid provides its own current authorization requirements, provider portal functions, manuals, and service specific guidance, which should be checked for each applicable service.
There is no single timeframe that applies to every authorization request. Processing time can depend on the payer, service, clinical documentation, request method, urgency, additional information requirements, and other factors. Nevada Med Billing focuses on submitting complete requests and following pending cases rather than assuming every payer will process requests on the same schedule.
Free revenue audit
Turn prior authorization into a managed process
Prior authorization should not depend on someone remembering to check a payer portal tomorrow. Nevada Med Billing gives your practice a defined process for authorization requirement checks, documentation preparation, submission, payer follow up, approval tracking, and authorization related billing support. If your physicians or internal staff are spending too much time chasing approvals, let us examine the workflow.