Prior authorization
Prior Authorization Services
We handle the paperwork and phone calls behind prior authorizations, so your staff spend less time on hold and fewer claims are denied for a missing approval.
What we handle
- Checking if authorization is required
- Preparing and submitting requests
- Tracking status until a decision
- Recording approved units and dates
- Denials, appeals and peer-to-peer prep
What is prior authorization in medical billing?
Prior authorization is a payer’s approval, required before certain services are performed, that confirms the service is medically necessary and covered under the patient’s plan. Without it, a claim for that service is usually denied, even when the care was appropriate. Payers commonly require it for advanced imaging, many surgeries and procedures, specialty drugs, durable medical equipment and some therapy visits, and each payer keeps its own list. Jupiter RCM checks whether a scheduled service needs authorization, gathers the clinical documentation, submits the request through the payer’s portal or other required channel, and follows up until a decision is made. We record the authorization number, approved units and dates, so the claim matches what was approved. If a request is denied, we tell you and help prepare an appeal or a peer-to-peer review. For Medicare Advantage, Medicaid and CHIP, a CMS rule in effect since 2026 requires decisions within 72 hours for urgent requests and 7 calendar days for standard ones, except for drugs.
The problem
Why prior authorizations slow practices down
Authorizations take staff time before the visit and cause denials after it when anything is missed.
How we handle it
What our prior authorization service covers
We work from your schedule and orders, request what we need from your clinical team, and keep you updated at each step.
- Checking authorization and referral requirements
- Collecting orders, notes and supporting records
- Submitting through payer portals and other required channels
- Tracking pending requests daily
- Responding to payer requests for more information
- Recording authorization numbers, units and date ranges
- Tracking expiring authorizations and extensions
- Coordinating peer-to-peer reviews with the provider
- Preparing appeals for denied requests
Payer deadlines
Decision timeframes under the CMS prior authorization rule
Since January 2026, the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) sets maximum decision times for many government-sponsored plans.
| Request type | Decision required within | Applies to |
|---|---|---|
| Expedited (urgent) | 72 hours | Medicare Advantage, Medicaid and CHIP (fee-for-service and managed care) |
| Standard (non-urgent) | 7 calendar days | Medicare Advantage, Medicaid and CHIP (fee-for-service and managed care) |
The timeframes do not apply to drugs or to Marketplace plans on the federal exchange, and commercial plans follow their own contracts and state rules. Payers must also give a specific reason when they deny a request, which makes appeals easier to target.
Process
How a prior authorization moves through our team
Identify
We flag scheduled services that need authorization during eligibility checks.
Prepare
We gather the order, clinical notes and codes the payer asks for.
Submit & track
The request is submitted and followed up until the payer decides.
Record
Approval details are noted so the claim matches what was authorized.
Resolve
Denials are escalated to appeal or peer-to-peer review with your provider.
Why it matters
What changes when authorizations are handled for you
FAQ
Prior Authorization Services: common questions
Who decides if a prior authorization is approved?
The payer does. We cannot guarantee approval, but a complete request with the right documentation avoids delays and denials caused by missing information.
Do you need access to our EHR?
Usually yes, with access you control, so we can see orders and pull the clinical notes the payer requires. We can also work from documents your team sends securely.
What happens if an authorization is denied?
We tell you the payer’s reason, and depending on the case, help prepare an appeal or schedule a peer-to-peer review between your provider and the payer’s medical reviewer.
Can you track authorizations that are about to expire?
Yes. We record approved units and date ranges and flag authorizations that need an extension before they run out.
Related services
Services that work alongside prior authorization
Let’s take a closer look at your revenue cycle
Tell us what’s getting stuck. Denials, old A/R, credentialing, reports nobody reads? We’ll look at how you work now and tell you straight what we’d change, and why.