ServicesThe revenue cycle
Prior authorization is the payer’s approval, before care is delivered, that a procedure, scan, drug or piece of equipment is medically necessary and will be covered. VisMed runs prior authorization for your practice from the order to the determination: requirement checks, clinical documentation, payer portal and ePA submission, daily follow-up, peer-to-peer coordination and appeals, inside your own EHR.
Reviewed by the VisMed revenue cycle team
A prior authorization problem rarely looks like one at first. It looks like a patient whose MRI was moved twice, a surgery slot that went unused, an infusion chair that sat empty, or a claim denied six weeks later for “no authorization on file.” Behind each of those is a request that went out late, went out without the notes the payer wanted, or was approved and then quietly expired.
Our prior authorization services treat authorization as a desk with a calendar, not a task someone gets to between phone calls. Every order is checked against the patient’s plan the day it is written. When an authorization is required, the request is submitted within one business day of the order, with the clinical documentation the payer’s policy actually asks for, and followed every day until there is a determination.
We handle procedure, surgery, imaging, medication, specialty drug, infusion, DME and urgent authorizations for physicians, medical groups, hospitals, therapists, clinics and laboratories across the USA, with Medicare, Medicaid and commercial payers. The approval, its authorization number and its approval window go into your EHR, attached to the scheduled service, so the claim that follows is paid.
For every order, we check whether this patient’s plan requires prior authorization or precertification for this CPT or HCPCS code, at this place of service. Requirements differ by payer, by plan within a payer, and by site of care, and they change several times a year. We check the current list, not last year’s.
We read the payer’s medical policy for the service and collect what it asks for from the chart: clinical notes, physician orders, imaging and lab results, failed conservative treatment, prior medications tried. When the notes do not yet show medical necessity, we tell your provider exactly what is missing before the request goes out.
Requests are submitted through the payer’s portal, its utilization management vendor, electronic prior authorization (ePA) built into your EHR, or by fax where a payer still insists on it, with the right CPT, ICD-10 and J-codes and the documentation attached. Each submission is logged with its reference number.
Every open request is checked daily until a determination arrives. When a payer asks for more information, we answer the same day we see the request. Nothing waits in a queue because nobody looked at the portal.
When a reviewer wants to speak to the ordering physician, we schedule the peer-to-peer review inside the payer’s window, brief your provider on the policy criteria and the case, and record the outcome.
Denials are appealed with a letter of medical necessity and the supporting records, inside the payer’s appeal window. Approvals that are close to running out of dates, visits or units are renewed or extended before the patient’s next scheduled service.
Six kinds of request, each judged against different criteria. What the payer usually wants to see decides what we pull from the chart.
Common examplesJoint replacement, spine surgery, arthroscopy, bariatric surgery, cardiac catheterization, sleep studies, outpatient and ASC procedures
What the payer usually wantsCPT codes, diagnosis, conservative treatment tried, imaging, surgical plan, site of service
Surgery authorization is usually tied to a specific facility and date range. If the date moves or the procedure grows on the day, the approval may no longer match, so we track both.
Common examplesMRI, CT, PET, nuclear cardiology, echocardiography, advanced ultrasound
What the payer usually wantsClinical indication, symptom duration, prior imaging, conservative care, ordering provider notes
Many plans hand imaging to a radiology benefit manager with its own portal and criteria. We know which one manages each plan and what it asks for.
Common examplesBiologics, oncology drugs, GLP-1 and other high-cost medications, non-formulary drugs
What the payer usually wantsDiagnosis, prior medications and outcomes for step therapy, lab values, dosing, J-code or NDC
Medication prior authorization often turns on step therapy: which drugs were tried, for how long, and why they failed. We find that history in the chart and put it in the request.
Common examplesChemotherapy, immunotherapy, IVIG, infliximab, joint and spinal injections, buy-and-bill drugs
What the payer usually wantsDrug and dose, J-code and units, number of doses, site of care, regimen
Infusion approvals cover a dose, a number of units and a date range. When a regimen changes, the authorization has to change with it, before the next infusion.
Common examplesPower mobility, CPAP and BiPAP, oxygen, hospital beds, orthotics and prosthetics
What the payer usually wantsPhysician order, face-to-face notes, test results, HCPCS codes and modifiers, rental or purchase
DME authorization depends on documentation in the physician’s chart, not the supplier’s. We collect it from the ordering practice and match it to the payer’s coverage criteria.
Common examplesUrgent imaging, oncology treatment starts, inpatient admissions, post-acute placement
What the payer usually wantsPhysician attestation that waiting could seriously harm the patient, plus the standard documentation
Urgent and expedited prior authorization requests go to the front of our queue and are followed hour by hour. Where a service was performed in an emergency, we request retro authorization if the payer allows it.
Authorization-heavy specialties where we run prior authorization most: Cardiology, Oncology, Orthopedics, Spine and neurosurgery, Gastroenterology, General surgery, Pain management, Radiology, Neurology, DME suppliers.
Nine checkpoints from the order to the appeal, run in five steps. Each one has an owner on our side.
The work starts when the order is written, not when the patient is scheduled. We review new orders and upcoming appointments every day, confirm the patient’s coverage, and check the payer’s current authorization list for the CPT or HCPCS code, the diagnosis and the place of service. Orders that need nothing are cleared. Orders that need authorization go straight to the desk.
What we doReview orders and the schedule daily, check each payer’s requirements by code and site of care
What you doPlace orders in the EHR as usual
We match the chart to the payer’s medical policy, criterion by criterion: diagnosis, symptom duration, prior treatment, test results, and for medications, the step therapy history. When something the policy requires is not in the notes, your provider gets a short, specific request rather than a denial three weeks later.
What we doGather notes, orders, results and history; draft the medical necessity summary; flag documentation gaps
What you doAdd any missing clinical detail when we ask
The request goes out within one business day of the order through the channel that payer works fastest in: its own portal, a utilization management vendor, ePA from inside your EHR, or fax. Codes, units, dates, site of service and the documentation are checked against each other before we submit.
What we doSubmit through the right portal or ePA channel, log the reference number
What you doNothing
Each pending request is checked every day. Requests for additional information are answered as soon as they appear. If the reviewer asks for a peer-to-peer, we book it, prepare your provider with the policy criteria and the key facts of the case, and follow up on the result.
What we doTrack status daily, answer payer requests, arrange and prepare peer-to-peer reviews
What you doTake the peer-to-peer call when one is needed
Approvals are recorded in your EHR with the authorization number, approved codes, units or visits, and the approval window, attached to the scheduled service. Denials are appealed with a letter of medical necessity inside the payer’s deadline. Approvals that are running low on dates, visits or units are renewed or extended before they lapse.
What we doUpdate the chart and appointment, write and file appeals, start renewals ahead of expiry
What you doSign the letter of medical necessity
From one physician’s orders to a hospital’s outpatient departments. The payers ask the same questions; the volume, services and specialties change.
We handle Medicare prior authorization, Medicaid prior authorization and commercial authorizations every day. Traditional Medicare requires authorization for a short list of services, while Medicare Advantage and Medicaid managed care plans require it for many more, and most large commercial payers send imaging, specialty drugs and some procedures to utilization management vendors with their own portals and criteria. We know which one manages each plan.
Payer names are trademarks of their owners. VisMed is not affiliated with or endorsed by any payer.
Where authorizations usually turn into delayed care, lost revenue or overworked staff, and what we do about each one.
When an authorization is still pending on the day of service, the visit is either moved or performed at the practice’s risk. Starting the request the day the order is written, and following it every day, is how we get you faster prior authorization approvals and fewer rescheduled appointments.
Most avoidable denials happen because the request did not show what the payer’s policy asks for: the weeks of physical therapy, the medication that failed, the imaging result. We check the chart against the policy before submitting, which is what produces a higher first-pass approval rate.
No authorization, authorization does not match the service, wrong number on the claim: these denials are among the hardest to overturn after the fact. Linking each approval to the scheduled service and checking it at charge entry means fewer authorization-related denials reach your A/R.
Approvals have a start date, an end date and a number of visits, units or doses. Treatment runs longer, a surgery is rescheduled, a dose changes. We track every authorization number and approval window and renew or extend it before the patient’s next scheduled service, not after the claim is denied.
Payers add and remove codes from their authorization lists several times a year, and federal rules are changing too: under CMS-0057-F, the Interoperability and Prior Authorization Final Rule, Medicare Advantage, Medicaid, CHIP and federal marketplace plans must send standard decisions within seven calendar days and expedited decisions within 72 hours from 2026, and offer prior authorization APIs from 2027. We track payer-specific authorization requirements so your team does not have to.
Prior authorization is hours of portal logins, faxes and hold time each week, usually taken from medical assistants and front-desk staff who are needed elsewhere. Moving that work to a dedicated desk gives you reduced staff workload without losing control of what is submitted.
In-house vs outsourced prior authorization usually comes down to focus. Authorization work is steady, detailed and deadline-driven, and in most practices it is done in between other jobs. Outsourcing prior authorization to a prior authorization company gives you dedicated prior authorization specialists who do nothing else, while approvals, documentation and reports stay inside your own EHR.
| Area | In-house, typically | Outsourced to VisMed |
|---|---|---|
| Who does it | Medical assistants or front-desk staff, between other tasks | Dedicated prior authorization specialists |
| Requirement checks | From memory, or when a claim is denied | Every order, against the payer’s current list |
| Follow-up | When someone has time to check the portal | Every pending request, every day |
| Expiry and renewals | Found when the next claim is denied | Tracked against the approval window and renewed ahead |
| Coverage | Stops when the staff member is out | A team covers your queue every working day |
| Reporting | Usually none | Daily authorization status reports |
Your requests are handled by a team that works prior authorization every day, knows the payer portals and policies, and learns your providers, your orders and your payer mix.
Requests are submitted within one business day of the order, urgent and expedited requests sooner, so the payer’s clock starts as early as possible.
We work inside the EHR you already use, including Epic, athenahealth, eClinicalWorks, NextGen, ModMed, AdvancedMD, Tebra and WebPT, and in the payer portals under your practice’s accounts. Approvals are recorded where your staff already look.
We sign a Business Associate Agreement (BAA) before we start, work inside your systems, keep no PHI on our own servers, and limit access to the specialists working your requests.
Every day you get a short report: requests submitted, pending, approved and denied, documentation we need from a provider, peer-to-peer calls booked, and authorizations close to expiry.
Start with a free AR audit: six months of aging and denials, quantified as monthly leakage with a recovery estimate, in two to three business days. It shows how much of your denial pile is authorization. Yours to keep.
or write directly hello@vis.med
What providers ask about prior authorization, and about working with VisMed, on the first call.
VisMed’s prior authorization services include authorization requirement checks for every order, clinical documentation and medical necessity review, submission through payer portals and ePA, daily status tracking and payer follow-up, peer-to-peer coordination, appeals, renewals and extensions, EHR updates with the authorization number and approval window, and a daily status report.
When VisMed runs your revenue cycle, prior authorization is included in the percentage of collections, with no separate charge. As a standalone service, prior authorization pricing depends on your monthly request volume, the types of authorizations and your payer mix, and VisMed quotes it in writing before work starts.
VisMed submits prior authorization requests within one business day of the order, and urgent or expedited requests sooner. Every pending request is followed daily until the payer makes a determination. How long the payer takes to decide depends on the payer and the service.
VisMed handles procedure and surgery authorizations, diagnostic imaging (MRI, CT, PET), medication and specialty drug prior authorizations, infusions and injections, durable medical equipment (DME), behavioral health and therapy authorizations, and urgent, expedited and retro authorizations where the payer allows them.
Yes. Urgent and expedited requests go to the front of the queue, are submitted as expedited with the physician’s attestation, and are followed through the day until there is a decision. For services performed in an emergency, VisMed requests retro authorization where the payer allows it.
Yes. VisMed schedules peer-to-peer reviews inside the payer’s window, prepares the ordering physician with the policy criteria and case facts, and records the outcome. If the request is denied, VisMed writes the appeal and letter of medical necessity and files it inside the payer’s deadline.
Yes. VisMed works inside your existing EHR, including Epic, athenahealth, eClinicalWorks, NextGen, ModMed, AdvancedMD, Tebra and WebPT, uses ePA where your EHR supports it, and submits through payer portals under your practice’s accounts.
Yes. VisMed handles authorizations for Medicare and Medicare Advantage, Medicaid and Medicaid managed care plans, and commercial payers including UnitedHealthcare, Aetna, Cigna, Blue Cross Blue Shield and Humana, along with their utilization management vendors, marketplace plans, TRICARE, VA Community Care and workers’ compensation.
Yes. Partial prior authorization support is common: only imaging, only specialty drugs, one location, or a backlog cleanup while your own team catches up. VisMed can also take over end-to-end prior authorization management, and the scope can change as you go.
Outsourcing prior authorization gives you dedicated specialists who check every order, submit within one business day and follow up daily, which means fewer rescheduled appointments, fewer authorization-related denials and less staff time on portals and payer calls. The work and the records stay in your own EHR.
