Prior authorization is a payer's requirement that you get approval before a service is delivered. The intent is to confirm the service is covered and medically necessary. The reality, for most practices, is a slow back-and-forth that ties up staff and delays care. When it goes wrong, the claim is denied even though the work was done correctly.
What prior authorization actually is
For certain procedures, imaging, and medications, the payer wants to sign off in advance. You submit clinical information, the payer reviews it, and an authorization number is issued. That number has to match the service and the codes you eventually bill. If the visit happens without an active auth, or the auth does not match the claim, the payer denies it.
Why auth denials happen
A handful of causes drive most authorization denials:
- No auth on file. The service required one and it was missed at scheduling.
- Mismatch. The auth covers a different code, date, or provider than what was billed.
- Expired auth. The visit slipped past the authorization's valid window.
- Missing documentation. The clinical notes did not support medical necessity.
Notice that all four are decided before the claim is sent. That is the opportunity.
How to prevent them
Build the check into scheduling, not billing. Flag every service that needs an authorization at the moment it is booked. Confirm the auth is active and matches the planned codes and provider. Keep the clinical documentation that supports necessity attached and current. When an auth is close to expiring, surface it before the visit, not after the denial.
Where Heron fits
Heron keeps authorizations moving alongside your team, including after hours, and checks that each auth matches the claim before anything ships. See how this works in denial prevention and the after-hours front desk.