Prior Authorization Services That Keep Care and Cash Moving
Approvals secured before the procedure date, not chased after the denial.
Physicians now handle about 40 prior authorizations a week, and every one that stalls is a delayed patient and a claim at risk. Our California authorization specialists take ownership of every request: we confirm the requirement, build a complete clinical packet, submit through the right channel, follow up until a decision, and appeal anything that comes back denied.
- Approvals secured ahead of the date of service
- Urgent requests worked same day
- Every denial reviewed within 48 hours
- HIPAA compliant with signed BAA
What Are Healthcare Prior Authorization Services?
Prior authorization (also called preauthorization, precertification or prior approval) is a health plan's requirement that a provider obtain approval before delivering a service, procedure, device or drug, or the plan will not pay for it. Healthcare prior authorization services take that work off your staff: a dedicated team confirms which services need approval, assembles the clinical evidence the plan expects, submits the request, follows it to a decision and manages any denial or appeal.
A referral and a prior authorization are not the same thing. A referral is a primary care physician's permission for a patient to see a specialist, common in HMO plans. A prior authorization is the plan's (or its delegated group's) approval of the specific service itself. Many California HMO patients need both.
Prior Authorization Services We Provide, End to End
One accountable owner for every request, from the first requirement check to the final claim.
Authorization Requirement Check
We confirm, by CPT or HCPCS code, plan and site of service, whether a service needs prior authorization, prior notification only, or nothing at all, and we document the answer so billing has proof.
Clinical Packet Preparation
We assemble what reviewers look for: diagnosis codes, prior conservative treatment, imaging and lab results, chart notes and a letter of medical necessity, mapped to the payer's clinical policy, InterQual or MCG criteria.
Submission Through the Right Channel
Payer portals, Availity, radiology benefit managers, X12 278, fax or phone, whichever each payer requires, with every submission time-stamped and referenced.
Proactive Follow-Up and Escalation
We chase pended requests and answer requests for additional information the same day. Urgent requests are flagged as expedited and escalated until a decision is in hand.
Pharmacy and Specialty Drug Authorizations
Medical-benefit drugs (J-codes, infusions, injectables) and pharmacy-benefit drugs through CoverMyMeds, Medi-Cal Rx and Part D coverage determinations, including step therapy exception requests.
Denials, Peer-to-Peer and Appeals
Every adverse determination is reviewed within 48 hours. We schedule peer-to-peer reviews for your physician, draft reconsideration and appeal letters, and pursue California Independent Medical Review when the facts support it.
Retro Authorizations
When a service had to happen before approval, we file retroactive authorization requests within the payer's window and build the case for payment.
Extensions, Units and Visit Limits
We track every authorization's valid dates, approved units and visits, and request extensions before an ongoing treatment plan runs out of coverage.
Mid-Treatment Coverage Changes
When a patient changes plans mid-course, we re-verify benefits and secure a new authorization before the next date of service.
Pre-Billing Authorization Match
Before a claim goes out, we match the authorization number, dates, units and codes to the claim, so authorization denials never reach the payer.
Prior Authorization in California: The Rules We Work By
Among prior authorization companies in California, few build their workflow around the state's own rules. We do, because knowing the deadline a plan must meet is what lets us hold it to that deadline.
Medi-Cal: TARs, Managed Care Plans and Medi-Cal Rx
Medi-Cal has three separate authorization paths, and sending a request down the wrong one wastes days. Fee-for-service Medi-Cal uses the Treatment Authorization Request (TAR), submitted as an eTAR through the Medi-Cal Provider Portal. Medi-Cal managed care plans such as L.A. Care, IEHP, CalOptima Health, Health Net, Molina and Partnership HealthPlan run their own utilization management, often delegated further to an IPA. Outpatient drugs on the pharmacy benefit go through Medi-Cal Rx. Children's services under California Children's Services use a Service Authorization Request (SAR). We route each request to the right one.
IPAs, Medical Groups and Delegated Utilization Management
For many California HMO members, the IPA or medical group, not the health plan, decides the authorization. We use the Division of Financial Responsibility (DOFR) to identify who owns each service, then submit to that entity in the format and timeframe it requires.
Decision Deadlines Plans Must Meet
| Rule | Applies to | Standard request | Urgent request |
|---|---|---|---|
| Knox-Keene Act (H&S Code 1367.01) | DMHC-regulated health plans | 5 business days after all needed information is received | 72 hours |
| CMS-0057-F (in effect since January 1, 2026) | Medicare Advantage, Medi-Cal (fee-for-service and managed care) | 7 calendar days | 72 hours |
Under Knox-Keene, the plan must also tell the provider its decision within 24 hours of making it. Emergency services cannot require prior authorization at all. We log every submission time so missed deadlines become leverage, not lost weeks.
Recent California Reforms Your Practice Should Know
SB 1120 (effective 2025)
A medical necessity denial must be made by a licensed physician or qualified clinician, not by an AI tool on its own. If a denial looks automated, we challenge it.
SB 306 (effective 2026)
Plans report approval rates by service to regulators by December 31, 2026. Starting January 1, 2028, services approved at least 90% of the time are exempt from prior authorization for state-regulated plans. We track which of your services drop off the list so you stop submitting unnecessary requests.
AB 347 (step therapy)
Plans must offer a step therapy exception process, and a request the plan fails to answer in time is deemed approved.
Independent Medical Review (IMR)
Members of DMHC-regulated plans can take a denied service to a binding external review run by the state, at no cost to the patient. We prepare the clinical record when it gets that far.
Note: SB 306 and Knox-Keene apply to state-regulated plans. Self-funded employer (ERISA) plans follow federal rules instead, and we verify which applies to every patient.
Our 8-Step Prior Authorization Process
Requests are submitted within one business day of a complete order. Urgent requests are worked same day, and denials are reviewed within 48 hours.
- 1
Intake
Orders arrive from your EHR, scheduling queue, fax or secure upload, and each one gets a tracking record and an owner.
- 2
Eligibility and benefits
We confirm active coverage, plan type, the responsible party (plan, IPA or medical group) and the patient's benefit for the service.
- 3
Requirement check
We confirm whether the exact codes, plan and site of service need prior authorization, notification only, or neither.
- 4
Clinical packet
We pull the documentation the payer's criteria call for and flag any gap to your clinical team before submission, not after a denial.
- 5
Submission
Sent through the payer's preferred channel, with the time, method and reference number logged.
- 6
Follow-up
Pended requests are worked daily. Urgent requests are escalated from the moment they are filed.
- 7
Decision
Approvals are posted to the chart and schedule with the authorization number, valid dates, approved codes and units. Denials go straight to peer-to-peer or appeal.
- 8
Claim match and renewal
We match the authorization to the claim before billing and set reminders for extensions on ongoing care.
Prior Authorization Support for Every Specialty and Service Type
Authorization rules differ by service. These are the requests we handle most, and the details that win them.
| Specialty | Authorizations we handle most |
|---|---|
| Radiology and imaging | MRI, CT, PET, nuclear cardiology, through Evolent, Carelon and eviCore |
| Orthopedics and spine | Joint replacement, arthroscopy, spinal fusion, injections, implants and DME, inpatient vs outpatient site of service |
| Cardiology | Cardiac catheterization, echocardiography, stress testing, device implants, cardiac rehab |
| Oncology and infusion | Chemotherapy regimens, immunotherapy, biologics and J-code drugs, radiation therapy plans |
| Gastroenterology | Advanced endoscopy, capsule studies, biologics for IBD |
| Behavioral health | Psychological testing, IOP and PHP, TMS, Spravato, ABA therapy, inpatient psychiatric admissions |
| Physical, occupational and speech therapy | Initial evaluations, visit-limit extensions, plan-of-care renewals |
| Pain management | Epidural injections, radiofrequency ablation, spinal cord stimulator trials |
| Sleep medicine | Home and in-lab sleep studies, CPAP and oral appliances |
| Surgery and ASCs | Elective procedures, bariatric surgery, plastic and reconstructive surgery (cosmetic vs medical) |
| DME and home health | Power mobility, CPAP, oxygen, wound care supplies, home health episodes |
| Primary care and endocrinology | GLP-1 and specialty medications, CGMs, advanced labs and genetic testing |
Practice types we serve: independent practices, multi-specialty groups, ambulatory surgery centers, infusion centers, FQHCs and community clinics, and hospital outpatient departments.
Payers, Portals and Utilization Managers We Work With
| Category | Names |
|---|---|
| Government | Medi-Cal fee-for-service (TAR/eTAR), Medi-Cal Rx, California Children's Services, Original Medicare (DMEPOS and hospital outpatient prior authorization), TRICARE West |
| Medi-Cal managed care | L.A. Care, Inland Empire Health Plan, CalOptima Health, Health Net Community Solutions, Molina Healthcare, Partnership HealthPlan, Anthem Blue Cross Partnership Plan, Blue Shield Promise, Kaiser Permanente, Alameda Alliance, Santa Clara Family Health Plan, CenCal Health |
| Commercial | Blue Shield of California, Anthem Blue Cross, UnitedHealthcare, Aetna, Cigna, Health Net, Sharp Health Plan, Western Health Advantage |
| Medicare Advantage | SCAN Health Plan, Alignment Health, Humana, UnitedHealthcare AARP, Wellcare by Health Net, Kaiser Senior Advantage |
| UM and benefit managers | Evolent (formerly NIA), Carelon Medical Benefits Management (formerly AIM), eviCore, Cohere Health, Turning Point, Optum, Magellan |
| Delegated groups | IPAs, medical groups and MSOs across Los Angeles, Orange County, the Inland Empire, San Diego, the Bay Area and Sacramento |
| Portals and ePA | Availity, CoverMyMeds, Surescripts, payer provider portals, Medi-Cal Provider Portal |
We work inside your systems
No new system to learn. Orders come from your EHR or PM, and every authorization is posted back to the chart.
Epic · athenahealth · eClinicalWorks · NextGen · AdvancedMD · Tebra · DrChrono · CureMD · ModMed
What You Can Expect From Our Prior Authorization Team
Prior Authorization Outsourcing Services Pricing
Clear starting prices, a fixed quote before we begin, and no surprise fees.
| Plan | Starting price | Best for | Includes |
|---|---|---|---|
| Standard authorization | $12 per request | Imaging, therapy visits, routine procedures | Requirement check, submission, follow-up to decision, posting to chart |
| Complex authorization | $28 per request | Surgery, oncology, infusion and specialty drugs, behavioral health levels of care | Everything above plus full clinical packet, criteria mapping, urgent escalation |
| Denials and appeals | $45 per case | Any denied or pended request, including ones we didn't submit | Denial review, peer-to-peer scheduling, appeal letter, IMR preparation |
| Dedicated authorization specialist | $2,200 per month | Groups with 300+ authorizations per month | Named specialist in your EHR, unlimited requests within contracted volume, daily reporting |
| Bundled with billing | Included | Practices using our medical billing service | Standard and complex authorizations included in your billing rate |
No setup fee and no long-term contract. Eligibility verification is included with every authorization request — see our insurance eligibility verification service.
Why Practices Trust Us
- HIPAA-compliant workflows and a signed Business Associate Agreement
- Minimum-necessary access to your EHR, with full audit trail
- Every request logged with time, channel and payer reference number
- Authorization specialists trained on California payers, Medi-Cal TARs and IPA processes
In-House Staff vs Software vs Outsourced Prior Authorization
| In-house staff | Prior authorization software | California Billing Services | |
|---|---|---|---|
| Who does the work | Your MAs, nurses and front desk | Your staff, with automation | Our dedicated authorization specialists |
| Clinical packet | Built when time allows | Pulls data, but someone must judge what's missing | Built to each payer's criteria before submission |
| Follow-up on pended requests | Often missed on busy days | Alerts, but no one calls the payer | Worked daily, escalated by deadline |
| Denials and peer-to-peer | Frequently written off | Not included | Reviewed within 48 hours and appealed |
| California routing (TAR, IPA, Medi-Cal Rx) | Learned case by case | Generic payer rules | Built into our workflow |
| Cost | Salary, benefits, training and turnover | Subscription plus staff time | From $12 per request, no contract |
Software speeds up the steps. People win the approvals. We bring both.
Prior Authorization Services FAQs
Prior authorization is a health plan's requirement that a provider get approval before delivering certain services, procedures, devices or drugs. Without it, the plan can deny payment. It is also called preauthorization, precertification or prior approval.
Can't find what you're looking for? Contact our billing specialists
Get Approvals Before the Patient Arrives
Send us 20 open or recently denied authorizations. Within three business days, a California authorization specialist will show you which ones can still be won, where your current process is losing time and what it would take to fix it. No cost, no obligation.
HIPAA compliant · BAA provided · No long-term contract
Talk to an authorization specialist
- Urgent requests worked same day
- Every submission time-stamped with a payer reference number
- Specialists trained on Medi-Cal TARs and IPA processes
- Denials reviewed within 48 hours and appealed
- Weekly status report on every open request
Keep authorizations and claims connected
An approved service still needs a clean claim. These services carry your revenue cycle through to payment.
Insurance Eligibility Verification
Coverage and benefits confirmed 48–72 hours before every visit.
Learn moreMedical Billing Services
Full-cycle billing that turns approved care into paid claims.
Learn moreRevenue Cycle Management
One accountable process from scheduling to the final zero balance.
Learn more