Writing prior authorization requests that hold up at the claim stage

Prior authorization is the insurer's agreement, before the service is given, that the service is needed for this patient. In Saudi Arabia, the request and the response are exchanged through NPHIES, usually from the clinic's own system.

The claim comes later and is checked again: against the approval, against the policy on the day of service, and against the documentation. Which services need approval at all depends on the insurer and the patient's policy, so check that alongside eligibility, before the plan is explained to the patient. The request and the claim have to tell the same story.

A reviewer reads the request with one question in mind: is this service needed for this patient now, and is it covered? A weak request is not necessarily wrong clinically. Often the doctor knew why the service was needed, and the request did not say it.

A request that holds up shows three things:

• The findings. The history, examination and results that link the condition to the service. A diagnosis on its own rarely makes the case.
• What was tried. The treatment by name, for how long, and how the patient responded. If a step was skipped, the reason: a contraindication, an intolerance or a warning sign.
• The exact service. Site, side, contrast, quantity and setting, written so the approval cannot be read two ways.

The same knee MRI request, written from memory and then from the visit note.

The revised version names the suspected tear as the question the scan will answer, not as a confirmed diagnosis. It also shows that simpler treatment came first.

A partial approval accepts part of the request: fewer units, a shorter period, or a different service from the one asked for. The claim will be checked against what was approved, not what was requested, so read the response before the patient is booked.

• Plan the treatment within what was approved, and tell the patient what is and is not covered.
• If the approved alternative is clinically acceptable, update the plan and the note so they match it.
• If it is not, respond before the service is given, with a new request or a request for review that states the clinical reason. The route available depends on the insurer.
• If more sessions are needed later, request them before they are given, with the progress so far and what the further sessions are for.

A request for more sessions that only says the patient still has pain gives the reviewer no reason to expect that more of the same will help.

By the time the claim arrives, the clinical decision has already been accepted. A rejection at this point is usually a mismatch between the claim and the approval. These are the ones to check:

• Diagnosis. The claim carries a different diagnosis from the request. That can be legitimate when the scan makes it more specific, but the record should show how one led to the other, and insurers handle it differently.
• Service. A study with contrast billed against an approval for one without, or a different side or site.
• Quantity. More units or sessions billed than were approved.
• Dates. The service given after the approval's validity period ended.
• Reference. The approval reference missing from the claim, so the claim cannot be matched to the approval.

Where an approval names a treating provider or a facility, that has to match too.

Plans change for sound clinical reasons. The radiologist recommends contrast, the surgeon finds more than expected, the patient needs another night in hospital. The approval does not change with them.

• If the change is known before the service, ask for an updated approval or send a new request first, and record the reason in the note.
• If it happens during a procedure, document the finding that led to it at the time and contact the insurer as the policy requires.
• Do not bill the changed service under the original approval. The claim will show the difference.
• Tell the billing staff what changed, so the claim is not prepared from the original request.

If the patient moves to a different policy between approval and service, the approval may not carry over. Check eligibility again on the day of service.

• An approval accepts the service as needed. It does not guarantee payment.
• Write the request from the visit note: the findings, what was tried, and the exact service.
• Read a partial approval before the patient is booked, and plan within it.
• Before the claim goes out, check the diagnosis, service, quantity, dates and approval reference against the approval.
• When the plan changes, update the approval first and record the reason in the note.