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What Are the Best Practices for Following Up on Pending or Denied Prior Authorizations?

Managing prior authorizations is a critical yet often frustrating part of healthcare administration. When requests are left pending or denied, they can create delays in patient care, disrupt workflows, and increase stress for both providers and staff. By implementing the best practices for pending prior authorizations, healthcare teams can streamline follow-ups, resolve issues promptly, and maintain smooth operations. A clear strategy ensures that pending cases are addressed on time, while denied authorizations can be resubmitted or appealed effectively.

The best practices for pending prior authorizations focus on proactive monitoring, thorough documentation, and timely communication with payers and providers. Whether the case requires a status check, additional documentation, or a formal appeal, having a structured process in place minimizes delays and keeps the patient’s care plan on track. This guide will equip healthcare providers with actionable steps to manage pending or denied prior authorizations with confidence and efficiency.

Key Takeaways

• Proactive monitoring of pending authorizations ensures timely resolutions.
• Understanding denial reasons and appealing promptly reduces backlogs.
• Documentation is critical: Keep thorough records for easy follow-ups.
• Automating reminders and creating a follow-up structure helps streamline the PA process.

1. Monitor Pending Authorizations Proactively

Pending authorizations can pile up quickly if not actively monitored. Assign dedicated staff or use tools to track pending cases regularly. Here’s how:

• Daily Status Checks: Review the status of pending prior authorizations daily in your insurance portals (e.g., Sunshine Portal, CMM, etc.). Make it part of your workflow to identify any updates.
• Pending Status Documentation: Maintain a shared spreadsheet or tracking tool listing pending PAs, dates submitted, authorization numbers, and follow-up timelines.
• Set Follow-Up Deadlines: If the payer’s timeframe for review is 5–7 days, schedule follow-ups on day 3 or 4 to stay ahead.

Example: “I submitted a PA for Dexcom G7 sensors. On day 3, I’ll check the Sunshine Portal for updates and follow up with a call if no changes appear.”

2. Understand Common Reasons for Denials

Denials often stem from missing details or miscommunications. By understanding the most common denial reasons, you can address issues proactively:

• Missing Documentation: Ensure all required medical records (e.g., recent office visits, lab reports, growth charts) are attached.
• Incorrect CPT or ICD Codes: Cross-check diagnosis codes and ensure they align with the service requested.
• Eligibility Issues: Verify insurance eligibility and plan details before submission.

When you receive a denial, look for the exact reason (e.g., “Diagnosis code mismatch”) and address it immediately.

Example: “The denial states a missing diagnosis code. I’ll pull the correct primary diagnosis (e.g., R62.52 for short stature) from the progress notes and resubmit.”

3. Establish a System for Appeals

Denied authorizations don’t have to mean the end of the road. Establish a clear process for resubmissions and appeals:

• Review Denial Letters: Carefully read the insurance company’s reason for denial.
• Correct Errors and Add Supporting Documents: Update any errors and attach all necessary clinical records to justify the request.
• Appeal Timelines: Note deadlines for appeals. Most insurers require appeals to be submitted within 30 days of the denial.
• Standard Appeal Templates: Create standard templates for appeal letters to save time.

Example: “The growth hormone test for Emma Sanderson was denied due to missing medical necessity documentation. I’ll resubmit the request with the growth chart, bone age X-ray, and recent office visit details.”

4. Maintain Thorough Documentation

Accurate documentation is key for both pending and denied cases. Always:

• Record Submission Details: Log reference numbers, dates, and authorization IDs in a centralized system.
• Attach Supporting Documents: Include office visits, lab results, and other supporting medical records to avoid delays.
• Save Communication Logs: Track all calls and messages exchanged with insurance companies or patients.

Keeping a complete paper trail ensures that you can easily revisit and resolve cases.

Example: “For any growth hormone-related test, I attach the X-ray, growth chart, and lab reports. I save the approval letter as ‘GH_stim_approval’ for future reference.”

5. Communicate Effectively With Insurance Providers

Building a relationship with insurance providers can speed up resolution times:

• Call Directly for Urgent Cases: For time-sensitive requests, call the insurance provider to clarify pending status or denial reasons.
• Document Contact Details: Maintain a list of payer-specific contacts for quicker follow-ups.
• Request Authorization Timelines: Ask payers for estimated resolution dates and flag urgent cases.

Example: “For urgent outpatient tests like the GH stimulation test, I always call Florida Blue directly to confirm processing timelines.”

6. Notify Providers and Patients

Keep stakeholders informed throughout the authorization process:

• Update Providers: Notify physicians about delays or denials to decide on alternative treatments if needed.
• Inform Patients: Communicate approvals, denials, or additional requirements to patients so they know what to expect.
• Provide Clear Instructions: Share details about next steps, such as resubmitting requests or scheduling tests.

Example: “I informed Dr. Pallav that no prior authorization was required for the GH stimulation test. I documented the reference ID and notified the facility.”

What Did We Learn?

Following up on pending or denied prior authorizations requires a clear strategy to avoid delays and frustration. By proactively tracking statuses, understanding denial reasons, and maintaining thorough documentation, you can efficiently resolve authorization issues. Effective communication with payers, providers, and patients ensures a smooth process and keeps care plans on track.

Frequently Asked Questions (FAQs)

1. How often should I check the status of pending prior authorizations?
It’s best to check daily, especially for urgent cases, to catch any updates and follow up proactively.

2. What are the most common reasons for prior authorization denials?
Missing documentation, incorrect CPT/ICD codes, and eligibility issues are the leading causes of denials.

3. How can I appeal a denied prior authorization?
Review the denial reason, correct errors, attach supporting clinical documents, and submit the appeal within the specified timeframe.

4. What tools can help with managing PAs?
Centralized tracking spreadsheets, electronic health records (EHRs), and payer portals are valuable for managing prior authorizations effectively.

5. Should I notify patients about delays or denials?
Yes, keeping patients informed ensures transparency and helps them plan next steps with their provider.

Disclaimer

The information in our posts is meant to inform and educate both healthcare providers and readers seeking a better understanding of healthcare processes. However, it is not a substitute for professional advice. Insurance requirements, policies, and approval processes can vary widely and change over time. For accurate guidance, healthcare providers should consult directly with insurers or use professional resources, while patients should reach out to their insurance providers or healthcare professionals for advice specific to their situation.

This content does not establish any patient-caregiver or client-service relationship. Staffingly, Inc. assumes no liability for actions taken based on information provided in these posts.

For tailored support and professional services,

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

Email : support@staffingly.com.

About the Author : Monica Michael is a seasoned Prior Authorization Specialist with years of experience in streamlining insurance processes for healthcare providers. She is passionate about simplifying complex administrative tasks to help hospitals focus on delivering exceptional patient care.