LTC Prior Authorization Services
Prior auth submitted, tracked, and appealed across MA plans, Medicaid managed care, and Medicaid waivers. CMS-0057-F is effective January 1, 2026 with a FHIR Prior Authorization API, a 7-day standard clock, a 72-hour expedited clock, and an annual public reporting requirement. Staffingly PA specialists work inside PointClickCare, MatrixCare, Availity, and each payer portal so authorization status sits next to the resident chart.
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0:48PA denials block admissions. Faxes get lost. Cash waits on auth.
Three prior-authorization pain points stall LTC admissions and post-acute claims every week. MA plans demand auth before SNF Part A coverage. Medicaid waivers require level-of-care determinations. CMS-0057-F adds reporting on top.
Fax queues and lost requests
Most MA plan PA still moves by fax or proprietary portal. Requests sit in queues for days. The 2024 AMA prior authorization survey reported that 94 percent of physicians said PA delays care, and 24 percent said it led to a serious adverse event.
Long PA cycle times
Standard MA plan PA still trends in the 7 to 14 day range despite the new CMS-0057-F 7-day rule effective January 1, 2026. Expedited PA must close in 72 hours. Facilities without a tracker miss both clocks.
PA denials and appeal windows
MA plan PA denial overturn rates on appeal exceed 80 percent per OIG OEI-09-18-00260, yet most facilities never appeal. The redetermination window is short, and a missed peer-to-peer review usually means the denial stands.
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What is an LTC prior authorization service ?
An LTC prior authorization service is a remote PA team that submits, tracks, and appeals authorizations for SNF and LTC admissions across Medicare Advantage plans, Medicaid managed care plans, Medicaid HCBS waivers, and select original Medicare items that still require PA under the CMS Required Prior Authorization List. The team works inside PointClickCare, MatrixCare, and each payer's portal so authorization status sits alongside the resident chart, not in a shared inbox.
What your prior authorization team actually handles, day to day
Pick the PA queues that hurt most. Your PA pod absorbs them. Your business office focuses on admissions and resident care, not the fax machine.
MA plan PA submission
Submits SNF Part A admissions and continued-stay requests through Availity, payer portals, and the FHIR PA API where the payer has live endpoints.
Medicaid waiver PA
Files level-of-care determinations for HCBS and institutional Medicaid waivers under each state's plan rules.
7-day and 72-hour clock tracking
Tracks the CMS-0057-F 7-day standard and 72-hour expedited timelines per case. Escalates before the clock runs out.
Peer-to-peer scheduling
Books peer-to-peer reviews with the plan medical director. Briefs the attending. Captures the outcome in the chart.
PA denial appeals
Drafts appeal letters that cite plan-specific medical necessity criteria, MDS sections, and physician orders.
FHIR PA API workflow
Uses the CMS-0057-F PA API where the payer has implemented it. Falls back to portal or fax when needed.
DMEPOS and Part B item PA
Submits PA for items on the CMS Required Prior Authorization List for original Medicare.
PA KPI reporting
Tracks PA volume, approval rate, average decision time, denial reasons, and appeal overturn rate by payer.
PA specialists who know the CMS-0057-F rule, not generic call-center reps
Most outsourcing companies hand you a call-center rep who fills out forms. We do not. Our PA specialists are post-acute trained, CMS-0057-F briefed, and payer-portal certified before they ever touch a live auth in your facility.
CMS-0057-F ready, day one
Every PA specialist is briefed on the January 1, 2026 effective date, the FHIR PA API, the 7-day and 72-hour clocks, and the annual public reporting requirement.
Stacked compliance posture
HIPAA + SOC 2 Type II + ISO 27001 + HITRUST. Plus alignment with 42 CFR 424 conditions of payment and 45 CFR 164.514 de-identification rules where applicable. Ask your current vendor for proof of all four.
2-Week Risk-Free Pilot
14 days of live PA submission and tracking at the same rate. Cancel before day 14, owe nothing. No annual contracts after.
Staffingly vs DIY in-house vs generic offshore vs onshore BPO
The real cost math for a single PA specialist FTE supporting a mid-size SNF or LTC operator.
From "let's talk" to live in 1 to 2 weeks
Six steps. Each one is documented.
Discovery call (15 min)
Which PA queue hurts most? MA plan SNF Part A? Medicaid waiver? DMEPOS? Home health PA? We map it on a shared call.
BAA + payer-portal access
Business associate agreement signed. Role-based access provisioned in PointClickCare, MatrixCare, Availity, and each payer portal you use.
Workflow shadow (2 to 3 days)
Your PA pod shadows your business office. Plan-by-plan medical necessity criteria captured. Escalation rules locked.
Parallel pilot starts
Week 2 to 3. Your PA pod runs alongside your team. Daily 15-minute sync. You see every PA submitted and every appeal drafted.
Decision point (end of week 2)
Pilot results reviewed. Approval rate, average decision time, denial reasons by payer, appeal overturn rate. Go or no-go.
Full handoff, cadence locked
PA KPIs in your inbox weekly. Monthly QA audit. Expansion paths discussed.
How your PA pod's day actually looks
A real shift, hour by hour. Times shown in your local time.
How Staffingly works, in practice
Inside the workA trained Staffingly specialist works inside your existing platform, with clear escalation back to your team.
One Flat Weekly Rate. No Surprises.
Dedicated senior care schedulers at a fixed weekly cost. Per scheduler FTE, per week. No contracts, no minimums, no hidden fees.
Want to compare against an in-house hire? Use the savings calculator.
Frequently asked questions
When is CMS-0057-F effective and what does it change?
The CMS Interoperability and Prior Authorization Final Rule, CMS-0057-F, is effective January 1, 2026 for impacted payers including Medicare Advantage, Medicaid fee-for-service, Medicaid managed care, CHIP, and QHPs on the federally-facilitated exchanges. It requires payers to implement a FHIR Prior Authorization API, decide standard PA within 7 calendar days and expedited PA within 72 hours, communicate a specific reason on every denial, and publish PA metrics annually.
What is the difference between expedited and standard PA timelines?
Under CMS-0057-F, standard PA must close in 7 calendar days from the date of receipt. Expedited PA, used when delay could seriously jeopardize life, health, or the ability to regain maximum function, must close in 72 hours. Both clocks include weekends. Our PA pod tracks every case against both clocks and escalates before the deadline.
How does the FHIR Prior Authorization API work?
CMS-0057-F requires impacted payers to expose a FHIR Prior Authorization API based on HL7 Da Vinci implementation guides. The API lets providers query PA requirements, submit requests, and receive decisions programmatically. Where the payer has live API endpoints, our PA pod uses them. Where the payer has not yet implemented, we fall back to the portal or fax workflow that payer requires.
How do you appeal a PA denial?
We read the denial reason on the payer notice, identify which medical necessity criteria the plan cited, draft an appeal letter that addresses each criterion with supporting documentation (MDS sections, physician orders, therapy notes, recent labs), and submit inside the redetermination window. For MA plan denials the typical redetermination window is 60 days. OIG OEI-09-18-00260 reported MA plan PA denial overturn rates above 80 percent on appeal.
Do you handle Medicaid waiver prior authorization?
Yes. Medicaid HCBS waivers and institutional waivers each require level-of-care determinations and service plan approvals under state-specific rules. Our PA pod files the level-of-care assessment, the service plan, and the cost-comparison documentation each state requires. We track approval and reauthorization windows per resident.
What about Medicare Advantage SNF Part A PA?
MA plans require PA for SNF Part A admission and most also require continued-stay PA at intervals tied to the plan's medical necessity criteria. Our PA pod submits the admission packet (face-to-face documentation, qualifying hospital stay, skilled need), tracks the 7-day or 72-hour clock under CMS-0057-F, and files continued-stay PA on the plan's cadence (often every 7 to 14 days).
How does pricing work for the PA team?
Per PA specialist FTE, per week. No setup fees. $399 Standard, $349 Volume (3 or more), $299 Enterprise (10 or more). Add or remove PA specialists by the week. No annual contracts.
What is included in the 2-Week Risk-Free Pilot?
Two weeks of live PA submission, tracking, and appeal work running in parallel with your business office. Full reporting on approval rate, average decision time, denial reasons by payer, and appeal overturn rate. No setup fee. No penalty if you cancel before day 14.
President and CEO, Staffingly, Inc. 25+ years in IT consulting and healthcare BPO operations. One of the earliest US operators to set up an RPO/BPO delivery network in India. Leads AI-driven home care workflows that help agencies, home health providers, and multi-branch operators cut admin cost without compromising care.
