What Is Prior Authorization?

Prior authorization (also called pre-authorization, pre-certification, or pre-approval) is when healthcare providers must obtain approval from the patient’s insurance company before delivering specific treatments, prescriptions, or procedures.

If prior authorization is not obtained, claims are often denied or underpaid, leading to revenue loss for the practice and unexpected bills for patients.

Why Prior Authorization Matters

• Prevents claim denials — Submitting PA requests correctly reduces denials and ensures timely reimbursement.

• Controls costs for payers — Insurance companies require it to ensure services are medically necessary and cost-effective.

• Reduces patient financial surprises — Patients are informed of approvals, coverage, or out-of-pocket costs before service.

• Ensures compliance — Many payers mandate PA for high-cost services like imaging, surgeries, and specialty medications.

Common Services Requiring Prior Authorization

• Advanced diagnostic imaging (MRI, CT scans, PET scans)

• Surgeries and inpatient admissions

• Specialty medications and infusions

• Durable medical equipment (DME)

• Behavioral health services

• High-cost therapies or procedures

Challenges Practices Face with Prior Authorization

• Complex payer rules — Different insurers have different requirements and submission processes.

• Time-consuming process — Manual calls, faxes, or portal submissions slow down practice staff.

• High denial rates — Missing documentation, incorrect codes, or delays in submission often cause denials.

• Patient dissatisfaction — Delays in treatment or lack of approval frustrate patients and affect their care experience.

How GladMedRCM Helps with Prior Authorization

We take the burden of prior authorization off your staff by managing the process end-to-end:

1. Eligibility & Benefit Verification — Confirming whether prior authorization is required for a service.

2. Documentation Preparation — Gathering necessary clinical notes, diagnosis, and supporting evidence.

3. Timely Submission — Submitting PA requests through payer portals, calls, or electronic systems.

4. Follow-Up & Tracking — Monitoring requests, expediting approvals, and preventing unnecessary delays.

5. Denial Management — Appealing denied PA requests with complete supporting documentation.

6. Patient Communication — Keeping patients informed about the status of their approval and expected costs.

Benefits of GladMedRCM Prior Authorization Services

• Higher approval rates with fewer delays

• Reduced claim denials related to missing PA

• Faster turnaround times for urgent cases

• Lower staff workload, saving hours on admin tasks

• Improved patient satisfaction and trust

• Increased revenue capture and consistent cash flow

Get Started with GladMedRCM

Prior authorization doesn’t have to be a bottleneck. With GladMedRCM’s expert prior authorization services, you can streamline approvals, reduce denials, and focus on delivering excellent patient care.

Contact GladMedRCM today for a free consultation and see how we can optimize your prior authorization process for better efficiency and stronger revenue results.