GoHealthcare Knowledge Center
Developed by GoHealthcare Practice Solutions
Our Prior Authorization Process
Prior Authorization Resource Center for Musculoskeletal and Specialty Care
GoHealthcare organizes the lifecycle into five phases: intake and case creation, coverage and clinical validation, submission and active management, determination and escalation, and procedural clearance and closure.
GoHealthcare Prior Authorization Statistics
Specialty Prior Authorization Performance
GoHealthcare-reported operational performance. Results may vary by payer, plan, specialty, case complexity, documentation quality, and client workflow.
01
Prior Authorization Resource Center
Phase One: Intake and Case Creation
Authorization quality begins with order quality and case-record accuracy.
- Receive and timestamp. Record source, method, date, time, service, clinical priority, and requested timeframe.
- Create the case. Capture patient, payer, plan, providers, facility, diagnosis, service, code, date, owner, status, and next action.
- Validate identity. Match the order, note, insurance, imaging, therapy, scheduling, and authorization records.
- Clarify service. Confirm intent, region, laterality, levels, units, visits, device, medication, site, and urgency.
- Reject ambiguity. Return incomplete or conflicting orders before payer submission.
02
Prior Authorization Resource Center
Phase Two: Coverage and Clinical Validation
The team identifies the exact plan and builds the clinical basis for the request.
- Eligibility and benefits. Verify coverage dates, product, referral, network, cost sharing, exclusions, and authorization requirements.
- Reviewer. Determine whether the payer, delegated UM entity, specialty pharmacy, or other party controls review.
- Policy. Locate the current authorization list, medical policy, delegated criteria, provider manual, and site rules.
- Medical necessity. Compare the record with diagnosis, symptoms, function, exam, imaging, conservative care, frequency, and sequence criteria.
- Gap resolution. Request the exact missing evidence rather than generic additional notes.
03
Prior Authorization Resource Center
Phase Three: Submission and Active Management
A clean submission is complete, consistent, traceable, and sent through the correct channel.
- Packet. Include order, recent note, diagnostics, treatment history, prior outcomes, therapy, imaging, codes, and forms.
- Channel. Use the required portal, EDI, fax, phone, or specialty-pharmacy pathway.
- Proof. Retain date, time, channel, confirmation, case number, documents, and submitting employee.
- Follow-up. Set the next action based on urgency, payer timeframe, scheduled date, and missing-information risk.
- Requests. Respond to additional-information requests with targeted evidence and document every communication.
04
Prior Authorization Resource Center
Phase Four: Determination and Escalation
Distinguish approval, partial approval, administrative denial, clinical denial, non-affirmation, and requests for information.
- Validate. Confirm code, service, provider, facility, site, region, laterality, levels, units, visits, and date range.
- Partial approval. Identify the exact unsupported component and choose correction, reconsideration, peer-to-peer, or appeal.
- Peer-to-peer. Provide policy, denial rationale, chronology, evidence, and desired resolution.
- Appeal. Use the correct level, deadline, recipient, format, and supporting record.
- Escalate. Use leadership pathways for urgent access risk, repeated payer defects, portal failures, and unresolved scheduled cases.
05
Prior Authorization Resource Center
Phase Five: Clearance and Closure
The case is complete only after operational readiness is confirmed and the record is closed.
- Scheduling clearance. Communicate approval details and limitations to scheduling, clinical staff, facility, patient, and financial counseling.
- Change control. Recheck authorization when date, provider, facility, code, laterality, levels, device, insurance, or plan changes.
- Expiration. Alert on start date, end date, units, visits, and remaining treatment capacity.
- Outcome. Record scheduled, completed, canceled, rescheduled, denied, appealed, or abandoned.
- Closure. Retain the complete activity history and ensure secure, auditable closure.
06
Prior Authorization Resource Center
Operational Controls and KPIs
Daily work queues, scheduled-case review, quality audits, and executive reporting control the process.
- Daily queues. Review urgent, scheduled, aging, missing-information, pending, appeal, and expiring cases.
- QA. Audit case creation, policy selection, packet completeness, proof, determination validation, and closure.
- Turnaround. Track total time and internal, provider, payer, and patient wait components.
- Defects. Separate intake, documentation, coding, policy, payer, and true medical-necessity issues.
- Capacity. Measure cases per FTE by complexity and work performed, not raw volume alone.
G
Operational Perspective
GoHealthcare Perspective
GoHealthcare Related Reading
Continue Reading on the GoHealthcare Website
These internal GoHealthcare resources were selected for this page because they directly expand the topic. Each address was checked against the live GoHealthcare website before this package was issued.
Our Prior Authorization Process
The complete GoHealthcare closed-loop authorization workflow from intake through case closure.
https://www.gohealthcarellc.com/prior-authorization-process.htmlUnderstanding the Prior Authorization Process
A foundational explanation of prior authorization, medical necessity, payer review, and workflow.
https://www.gohealthcarellc.com/blog/understanding-prior-authorization-process10 Proven Tips for Streamlining Prior Authorization
Practical guidance on documentation, electronic workflows, communication, tracking, and payer relationships.
https://www.gohealthcarellc.com/blog/10-proven-tips-for-streamlining-the-medical-prior-authorization-process-for-healthcare-providersCase Study: Prior Authorization Backlog Support
A case study on backlog recovery, payer follow-up, workload stabilization, and sustainable authorization operations.
https://www.gohealthcarellc.com/case-study-prior-authorization-backlog-pain-practice.htmlCase Study: Prior Authorization and Clinical Operations Support
A case study on clinically informed authorization, workflow control, tracking, scheduling, and patient access.
https://www.gohealthcarellc.com/case-study-prior-authorization-clinical-operations.htmlAuthoritative References
Verified Sources and Related Resources
Policies, authorization lists, code sets, and utilization-management criteria change. Verify the live source for the patient, payer, plan, jurisdiction, reviewer, provider, facility, service, and date.
CMS Interoperability and Prior Authorization Final Rule CMS-0057-F
https://www.cms.gov/initiatives/burden-reduction/overview/interoperability/policies-regulations/cms-interoperability-prior-authorization-final-rule-cms-0057-fCMS Medicare Coverage Database
https://www.cms.gov/medicare-coverage-database/search.aspxCMS Prior Authorization and Pre-Claim Review Initiatives
https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiativesStrengthen Prior Authorization Operations
GoHealthcare Practice Solutions supports specialty practices, ASCs, hospitals, and healthcare organizations with prior authorization operations, medical-necessity workflows, clinical documentation, denial prevention, appeals, analytics, and AI governance.
Developed by
Pinky Maniri
MSc, BSc, CRCR, CSAPM, CSPPM, CSBI, CSPR, CSAF, Certified in Healthcare A.I. Governance
Founder and Chief Executive Officer, GoHealthcare Practice Solutions
Professional and Educational Disclaimer
This content is provided for general professional, operational, educational, and informational purposes. It is not medical, legal, regulatory, compliance, coding, billing, reimbursement, financial, payer-specific, workers compensation, motor vehicle, or insurance advice. It does not establish coverage, medical necessity, authorization, reimbursement, payment, legal responsibility, or clinical outcome.
Healthcare organizations and professionals must independently verify current CMS, MAC, Medicaid, payer, utilization-management, coding, contract, facility, jurisdiction, and legal requirements. Clinical decisions remain the responsibility of appropriately licensed professionals. Legal questions should be reviewed by qualified counsel. CPT is a registered trademark of the American Medical Association.