Where authorizations go wrong
An authorization denial (adjustment reason code 197) is one of the most expensive denials a practice can get, because it usually hits high-value procedures and is hard to overturn after the fact. It rarely happens because nobody asked for approval. More often the approval was for a different code than the one performed, covered a different site or date range, expired before the service, or was requested from the wrong entity — the health plan instead of the benefit manager it delegates imaging or cardiology reviews to.
Our authorization workflow
- Requirement checkWhen a service is ordered, we check whether this payer and plan require authorization for that code, place of service and diagnosis, and who reviews it.
- Clinical packetWe assemble the documentation the payer’s criteria ask for — prior treatment, test results, imaging, the ordering note — and submit through the right portal or electronic transaction.
- Daily trackingPending requests are followed up until a decision is issued; the scheduler is told the status before the patient is booked or confirmed.
- Denial responseIf a request is denied, we arrange a peer-to-peer review with the medical director and prepare the clinician with the criteria in question.
- Match at billingBefore the claim goes out, the codes performed are compared with the codes approved; if the procedure changed, the payer is contacted about an update where the plan allows it.
Retro-authorizations and urgent cases
Some plans accept a request after an urgent or emergent service within a short window; many do not accept them for elective care. Knowing each plan’s rule in advance — and documenting why a service was urgent — is the difference between a payable claim and a write-off.
Specialties where this matters most
Authorization volume and risk are highest for advanced imaging, cardiac testing and procedures, orthopedic surgery and injections, GI procedures under some commercial plans, infusion and specialty drugs, and certain behavioral health levels of care. See how we handle it in cardiology, orthopedics and gastroenterology. For the wider picture of why claims are denied, read how to reduce claim denials.