Authorization Request Process Flow in a Provider’s Office

When a patient books an appointment or visits a provider, the patient’s diagnosis and service information are updated in the EHR. Before the provider can proceed with the treatment for the patient, an authorization request must be raised to the payer. The authorization coordinator on staff at the provider’s office is responsible for handling the end-to-end authorization process of the patient’s services. On receiving an approval for the requested services from the payer, the provider can proceed with care delivery.

Let’s see how authorization coordinators manage requests:

1. View and retrieve patient information, clinical data (diagnosis and service), requesting and servicing provider details, and more from the EHR system.
2. Check the need of authorization for the requested services or diagnosis from the payer.
3. Create and submit authorization requests, with necessary details and documents, to the payer based on the defined requirements.
4. Follow up on the status of the submitted request.
5. Provide additional information to the payer to enable prompt decision making.
6. Receive the determination in a timely manner so that patient care is delivered as planned.
7. After the request is approved, submit approval reference details to the payer for processing claim submissions. If the request is denied, raise an appeal request with the payer for reconsideration or request for a peer-to-peer meeting.