Prior Authorization Made Simple | Your Real-World Workflow in 5 Steps

patient access prior authorization rcm mastery Jul 31, 2025

Prior authorization shouldn’t be a daily disaster—but for many front desk and billing teams, it still is. Missed information, incorrect CPT codes, and unclear payer rules cause delays, denials, and frustrated patients.

In this quick-read blog, we’ll walk through a 5-step, real-world workflow that aligns with our crash course on Prior Authorization—built for busy healthcare professionals who need immediate results.

✅ Step 1: Verify Insurance Eligibility First

Before anything else, check the patient’s eligibility and benefits.
Use tools like Availity Essentials or payer portals to confirm:

Is prior auth required for this CPT/procedure code?
Are the patient’s benefits active?
What is the coverage policy?

📌 Pro Tip: Print or screenshot the eligibility confirmation and attach it to the patient record.

✅ Step 2: Use the Correct CPT & ICD-10 Codes

Prior auth can get denied if the codes don’t match medical necessity or policy guidelines.
Double-check with your provider:

CPT codes (procedure)
ICD-10 codes (diagnosis)

📌 Pro Tip: If you’re unsure, ask the provider or coder to confirm clinical documentation.

✅ Step 3: Submit to the Correct Payer or Portal

Each payer has different portals and requirements.
Use:

Availity
Navinet
Direct payer websites

📌 Pro Tip: Track all auth numbers and reference IDs—store them with the patient chart.

✅ Step 4: Follow Up and Document Everything

Don’t assume approval went through. Always:

Call to confirm
Request written confirmation
Enter notes in your EHR/PM system

📌 Pro Tip: Create a “Prior Auth Follow-Up Log” and update it daily.

✅ Step 5: Check Authorization Expiration and Scheduling Windows

Many prior auth approvals expire within 30–90 days or are tied to a specific provider or location.
Make sure:

The scheduled procedure matches the auth
It’s within the approved date range