Prior authorization stops being a guessing game when you know who governs the plan, who actually decides, how long they have, and where the request goes. This is that map, built for billing students and kept open all day by working billers.
From $19 a month. Included for students in the Medical Receptionist and Biller Course.
Federal rules, CMS-0057-F Primary
7 calendar days standard, 72 hours expedited
The plan, or the imaging reviewer it delegates to. The payer file names which.
The plan's provider portal, or the reviewer's
Authorization number in item 23 of the CMS-1500
The rules live in federal regulations, fifty one state laws, hundreds of payer policies, and the websites of the review companies payers hire. Most new billers learn them one denial at a time. The navigator puts the five questions in order and answers each one.
Medicare, Medicaid, a state regulated plan, or a self funded employer plan that state law does not reach.
The payer itself, or a reviewer such as eviCore, Carelon, or Evolent working on its behalf.
The deadline that applies, standard and urgent, and what happens when it is missed.
The right portal, phone line, or fax for that payer and that service.
Where the authorization number belongs so the claim matches the approval.
Opens in your browser. Search a state, filter payers, and tick off the steps as you work a request.
Seven landscape pages you can print for the desk or keep beside your screen.
Every state row says how solid its source is. Primary means the statute or insurance department. Secondary means a published summary to confirm. Not found means no state deadline exists, so plan and federal rules apply. You always know what you are leaning on.
Prior authorization is where new hires get lost, because no two payers do it the same way. The navigator shows you the pattern underneath all of them.
You already know prior auth. What you do not have is everything in one place, current, with the source beside every rule.
On the first of every month, the sources behind the navigator are checked again. Anything that moved is logged, reviewed, and updated, and the check date shows at the top of every page.
Federal decision deadlines take effect for Medicare Advantage, Medicaid, and CHIP plans: 72 hours expedited, 7 calendar days standard.
Traditional Medicare begins prior authorization for selected services in six states through the WISeR model, with outside review companies making the calls.
States keep moving: new laws in Delaware, Utah, Virginia, Massachusetts, and Minnesota change deadlines or remove prior auth for whole service lines.
Most billing problems leave clues. Prior auth is no different. Once you see the pattern, every payer starts to look familiar.
Marie Matteson, MS. Thirty years in healthcare, including twenty one as an EMT, and years of consulting with practices on their billing systems. Creator of the Medical Receptionist and Biller Course.
Both plans include the full navigator, the seven page flow sheet, and every monthly update for as long as your subscription is active.
Full access, renewed monthly. Cancel any time and it will not renew again.
Continue to checkoutTwelve months of access and updates for less than nine months of the monthly price.
Continue to checkoutEnrolled in the Medical Receptionist and Biller Course? The navigator is part of your prior authorization lesson. Nothing extra to buy.
About the coursePrices in United States dollars. Digital access is instant after checkout. Subscriptions renew automatically until you cancel, and charges already made are final with no refunds.
Yes. Every state and the District of Columbia has its own row with the standard and urgent deadline, the law behind it, and how solid the source is. The payer files cover national carriers and the Blue plans in every region.
No. The payer's own policy and the member's plan documents are always the final word. The navigator tells you which rules apply, where to look, and what to ask, so the call is shorter and the request is right the first time.
They follow federal rules, not state deadlines, and the navigator shows you how to spot one. That single check prevents a lot of wrong answers.
You receive a member login right away. The navigator runs in your browser and works best on a laptop or desktop. The flow sheet is a PDF you can download and print.
You do not have to do anything. When a rule changes, I review it and update the navigator and flow sheet in your member area, and the check date at the top changes. Just open it the way you always do.
Yes, any time. Once you cancel, the subscription does not renew. Charges already made are not refunded.
No. It is an educational reference. Laws and payer policies change, so confirm the rule with the payer or the state before you rely on it for a specific patient.
Pick monthly or annual below. Your login arrives as soon as checkout is complete.