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How Do You Train New Healthcare Staff on Prior Authorization Step by Step?

Prior Authorization for Gastroenterology Visits plays a vital role in the healthcare workflow, especially for specialty procedures like colonoscopies and endoscopies. It ensures that insurance providers review and approve services before patients receive them, which helps prevent coverage denials and unexpected costs.

This guide walks you through the prior authorization process step-by-step, using the example of Patient Y, who is scheduled for a colonoscopy. Whether you’re onboarding a new staff member or training an entire team, you’ll see how Staffingly actively manages and streamlines prior authorizations for gastroenterology visits.

What Is Prior Authorization?

Prior authorization (PA) is a requirement by many insurance providers to review and approve certain medical services before they are delivered. It ensures:

• The service is medically necessary

• The patient’s plan covers it

• The provider receives pre-approval, reducing denial risks

For practices, skipping this step can lead to claim rejections or non-payment. Staffingly handles this on the provider’s behalf to ensure compliance and timely service delivery.

When Does Prior Authorization Happen?

Prior authorization should occur before the procedure is scheduled or performed. Typically, this is during:

• Scheduling

• Pre-visit planning

• After referral is received

Staffingly starts the PA process immediately after the procedure is ordered to prevent delays.

Step-by-Step Prior Authorization Process

Let’s walk through the Staffingly method for managing a prior authorization request from start to finish.

Step 1: Determine If Authorization Is Needed

Staffingly reviews the scheduled procedure and the patient’s insurance plan. In this example, Patient Y is scheduled for a colonoscopy, which does require authorization under most insurance plans.

Step 2: Collect Clinical Documentation

Staffingly gathers necessary documentation from the referring provider, including:

• Office notes

• Diagnosis codes

• Medical necessity statement

• Previous test results

Step 3: Log Into the Payer Portal

Depending on the insurance, Staffingly accesses the correct portal:

• Availity (for BCBS/Florida Blue)

• Navinet (for Aetna)

• Or calls the insurance company if no digital portal is available

Step 4: Enter the Patient and Procedure Details

Details entered include:

• Member ID

• Date of birth

• Procedure CPT code (e.g., 45378 for colonoscopy)

• Diagnosis code (e.g., K63.5 for polyp)

Staffingly ensures no typos or missing fields, which could result in delays.

Step 5: Submit the Authorization Request

Staffingly collects the necessary documents and submits the authorization request electronically through the payer portal. They save the reference number and send a confirmation to the provider immediately.

Step 6: Track and Follow Up

Staffingly monitors the authorization status every day:

• If the insurance approves the request, they record the authorization number and its approval dates.

• If it remains pending, the team follows up directly with the insurance company.

• If the request is denied, Staffingly initiates an appeal by submitting additional documentation.

Step 7: Notify the Patient and Provider

After receiving the approval, Staffingly promptly notifies the provider and updates the system. If the insurance denies the request, Staffingly immediately informs both the patient and the provider, along with recommended next steps.

Step 8: Document the Outcome

Staffingly enters all final authorization details into the EMR or billing software, including:

• The authorization number

• The validity period

• The approved procedures

• Any notes regarding the patient’s financial responsibility

Why This Process Matters

Prior authorization reduces billing risk and increases patient satisfaction. Here’s how:

• For Patients: No surprises on bills.

• For Providers: Fewer denials, better cash flow.

• For Admins: Clear communication and documentation.

Staffingly ensures all parties are on the same page before care is delivered.

What Did We Learn?

From this guide, we’ve clearly seen that prior authorization is not just a formality — it is a crucial process for confirming coverage before providing care.

• First, it’s essential to verify the medical necessity of a procedure, submit the required documentation, and track the authorization status actively.

• Next, we learned that Staffingly’s structured approach improves accuracy, maintains compliance, and ensures timely communication with both patients and payers.

• Moreover, submitting prior authorization requests on time helps avoid costly delays or outright denials of service.

• Finally, for new staff, mastering this step-by-step workflow means you’ll stay aligned with insurance guidelines and support your practice’s operational success.

What People Are Asking

Q1: How long does it take to get prior authorization?
A: It can take anywhere from 24 hours to 7 days, depending on the insurance company and the complexity of the procedure. Urgent requests can be expedited.

Q2: What happens if a procedure is done without prior authorization?
A: The claim may be denied, and the cost could fall entirely on the patient or provider.

Q3: Can the provider appeal a denial?
A: Yes. Staffingly supports appeals by resubmitting with updated documents and handling phone or written appeals with the payer.

Q4: Do all insurances require prior authorization for colonoscopies?
A: Not always. It depends on the insurance plan, the type of colonoscopy (screening vs. diagnostic), and the patient’s risk factors.

Q5: How do we know if a CPT code needs authorization?
A: Staffingly maintains an updated list and uses payer-specific tools (like Availity) to verify which services need prior approval.

Disclaimer

For informational purposes only; not applicable to specific situations.

For tailored support and professional services,

Please contact Staffingly, Inc. at (800) 489-5877

Email : support@staffingly.com.

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