Prior Authorization & Appeals: The Full Workflow

This builds on the basics covered in Prior Authorization Basics. That article covers what prior auth is and the timing rule that matters most (it has to happen before treatment). This one goes further: which services typically need it, how to track a request end to end, realistic timelines, and what to do when a claim gets denied anyway.

When prior authorization is typically required

As a general pattern, exams, consultations, 2-D screening radiographs, and adult home sleep tests usually don't require pre-authorization. The services below typically do — though the exact list varies by payer, so treat this as a starting checklist to verify against each plan, not a universal rule.

Service	PA typically required?	Notes
Exams, consults, 2-D radiographs	No	Routinely covered when a medical diagnosis supports the visit
Surgical procedures	Yes	Follows the payer's surgical-services policy
Certain extractions and lesion excisions/biopsies	Varies	Some payers list specific exceptions — verify per payer
Oral appliance for sleep apnea (DME)	Yes	Requires the sleep study, prescription, and CPAP-intolerance documentation
TMJ surgery, advanced imaging (MRI, CT)	Yes	Advanced/surgical TMJ services almost always require PA
Orthognathic surgery	Yes	Predetermination is typically expected as well
Polysomnography / PAP devices	Yes	Falls under the payer's sleep-medicine policy
Injectable drugs (e.g., therapeutic Botox)	Yes	Usually authorized through the pharmacy benefit; the injection procedure itself may need separate medical PA at some payers

What each side of the practice needs to do

Clinical team:

• Assemble the documentation that actually proves necessity: the operative plan, imaging, sleep study, headache diary, or record of prior treatments that failed.
• Be available for a peer-to-peer review. This is when the provider speaks directly with the payer's medical reviewer, and it's one of the more effective ways to overturn a denial.
• Apply your own medical-necessity standard before submitting. Don't rely on the payer to find the justification for you — if it isn't clearly documented, assume it won't get read favorably.

Administrative team:

• Confirm whether PA is required for the specific code, using the table above as a starting point and the payer's actual policy as the source of truth.
• Assemble the full PA packet: demographics, the diagnosis and procedure codes in the right priority order, the LMN, and any required attachments.
• Submit through the payer's preferred channel — usually a portal, with fax as a fallback.
• Record the reference number, date, time, and the name of whoever you spoke with on every call. This matters more than it sounds like it should — a payer is generally bound by what it told you, and that record is what wins an appeal later.
• Put the PA number on the claim once approved, and re-check status weekly until it's resolved one way or the other.

Typical PA paths for major national payers

Payer	Primary submission path	Fax (fallback)
Cigna	Electronic PA via CoverMyMeds / SureScripts	866-873-8279 · 855-840-1678
UnitedHealthcare	UHC Provider Portal (Optum) / EDI 278	855-352-1206 (varies by plan/state)
Aetna	Availity Essentials	833-280-5224
Anthem (Elevance)	Interactive Care Reviewer via Availity	844-490-4876

Regional Blue Cross Blue Shield plans typically run their own state-specific portal and prior-auth form. Some states mandate a uniform medical prior-authorization form that all health insurers in that state have to accept — worth checking whether yours does. When one exists, it typically requires patient demographics, insurance ID, referring and rendering provider NPI/TIN, type of service, dates, primary diagnosis and code, and procedure name with CPT/HCPCS.

Realistic timelines

Stage	Typical window
Standard prior authorization	5–15 business days, often closer to 5
Urgent / expedited PA	24–72 hours
Predetermination (written benefit estimate)	~3 days by fax
Claim payment clock	~30–45 days; incomplete claims can add up to 60 more
Recommended internal follow-up	Re-check PA status weekly; follow up on submitted claims at ~3 weeks

The 3-level appeal process

More than half of denial appeals commonly succeed, which makes appealing worth the time in most cases. Two things worth checking before you start: read the payer's published medical policy first, and don't appeal a service the policy explicitly excludes as experimental — that specific fight is rarely winnable through the standard appeal path. (Before appealing, confirm you're dealing with a fixable denial and not a structural one — see Reading a Denial.)

1. Level 1 — Reconsideration / peer-to-peer. Ask the payer to reconsider the decision. The provider can request a peer-to-peer conversation directly with the payer's medical reviewer. A strong, specific appeal letter resolves the majority of simple appeals at this stage.
2. Level 2 — Medical-director review. A payer medical director who wasn't involved in the original decision reviews the case fresh.
3. Level 3 — Independent external review. An outside reviewer, often alongside a same-specialty physician, makes the final call. This is used when the internal appeal levels don't resolve it.

Common PA and appeal failures

Failure	How to avoid it
Incomplete PA form	Complete every field and attach clinical documentation upfront, rather than waiting for the payer to ask.
Missing reference number	Record the date, time, agent name, and reference number on every call, without exception.
Appealing an excluded service	Read the payer's medical policy before appealing — don't spend the effort on an explicitly excluded/experimental service.
Missed deadline	Appeal deadlines are strict and unforgiving. Calendar them and track weekly.
No patient authorization on file	Capture authorization to submit claims, share information, and appeal on the patient's behalf at intake, before you need it.

Building your own payer notes

Since PA requirements and submission channels vary so much by payer, it's worth building a short internal note for each of your top payers as you learn them: which services need PA, the preferred submission channel, and any state-specific forms required. Payers are gradually shifting toward electronic prior authorization, so expect fax to become more of a fallback than a primary channel over time — but that transition isn't complete industry-wide yet.

Medicare and Medicaid differences

Medicare: Prior authorization is limited to specific DME/prosthetics/orthotics/supplies (DMEPOS) categories and certain hospital-outpatient procedures, and is handled through the regional Medicare Administrative Contractor (MAC) rather than a general payer process. Medicare Advantage plans, by contrast, follow their own commercial-style PA processes.

Medicaid: Forms and PA rules are state-specific. If you're expanding into new states, build the PA workflow per state rather than assuming what worked in one transfers directly.