Requirement screening
Scheduled procedures screened against payer policy so nothing is delivered without needed approval.
Prior Authorization
Prior Authorization Support Without the Clinic Bottleneck
Authorization work pulls clinical staff away from patients. RCM Nexa handles requirement checks, submissions and payer follow-up so approvals move while your team stays focused on care.
Overview
Why this work decides whether you get paid
Authorization work is administrative, deadline-bound and clinically sensitive at the same time — which is why it slips. A missed authorization does not merely delay payment; it usually eliminates it, with no appeal path that recovers the full amount.
RCM Nexa identifies which scheduled services require authorization, submits requests with the clinical documentation each payer's policy demands, tracks decisions to closure, and manages expirations and unit counts so approvals still valid on paper are also valid in practice.
Who this is for
- Imaging, surgical, infusion and behavioral health providers
- Practices with authorization-related write-offs
- Specialties with unit-, visit- or frequency-limited services
- Teams whose clinical staff are absorbing payer phone time
What this includes
- Authorization requirement checks by payer and CPT
- Submission with clinical documentation support
- Active follow-up until determination
- Expiration and visit-limit tracking
Submission management
Requests filed through payer portals or fax workflows with documentation your clinical team provides.
Follow-up and escalation
Pending requests are worked daily, with peer-to-peer coordination requests routed to your providers.
Auth tracking
Approved units, date ranges and expirations tracked so care is not delivered outside the authorization.
How We Run It
Our prior authorization workflow
A defined sequence with named ownership at every handoff, so accountability does not disappear between steps.
Identify requirements
Scheduled services are checked against payer policy to determine whether authorization or notification is required.
Submit with support
Requests are filed with the clinical criteria, codes and documentation the specific policy requires.
Track decisions
Pending requests are followed until approval, denial or peer-to-peer, with escalation before the service date.
Manage validity
Approved units, date ranges and code sets are monitored so extensions are requested before care is delivered outside them.
Common Problems
What usually goes wrong — and how we handle it
Service delivered outside the approved window
Expiration and unit tracking flags exposure before the appointment, not after billing.
Approvals cover the wrong code
Requested codes are reconciled with the codes actually billed, and amendments are filed when plans change.
Clinical staff spend hours on payer holds
Administrative authorization work moves to our team; clinicians are involved only for peer-to-peer review.
Common Questions
Questions we get asked about prior authorization
- Who provides clinical justification?
- Your clinical team owns clinical content. We assemble, submit and pursue the request around it.
- Can you handle urgent requests?
- Urgent handling is defined during onboarding, including how your team flags time-sensitive cases to us.
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Talk to an RCM expert about your revenue cycle
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