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Prior Authorization, Done Right
Practical guidance for reducing turnaround pressure without cutting corners on documentation or clinical rigor.
Prior Authorization, Done Right
Practical guidance for reducing turnaround pressure without cutting corners on documentation or clinical rigor.
Prior authorization gets blamed for a lot of friction in health care — turnaround delays, provider frustration, member complaints. Most of that friction traces back to a handful of fixable process gaps, not the concept of prior authorization itself. Here's what actually moves the needle.
Start With Documentation Completeness
The single biggest driver of turnaround delay isn't review capacity — it's incomplete submissions. A request that's missing clinical notes, prior treatment history, or specific diagnostic detail can't be decided on the first pass, and every round-trip back to the provider adds days. Build intake requirements around what a reviewer actually needs to make a same-visit decision, and make those requirements visible to submitting providers before they submit, not after.
Keep Criteria Aligned and Current
Prior authorization criteria that lag behind current clinical guidelines create two problems at once: appropriate care gets delayed, and the denials that don't hold up become the ones that get appealed, litigated, or flagged in an audit. Review and update criteria on a defined cycle, tied to the guideline sources they're built on, rather than on an ad hoc basis when someone notices a problem.
Build Around the New Federal Timelines
CMS-0057-F requires impacted payers to decide expedited requests within 72 hours and standard requests within seven calendar days, and to give a specific reason for every denial. Those requirements, along with the required FHIR APIs and public reporting, take effect January 1, 2027, and are the operational reality UM teams are building toward.
Manage Peer-to-Peer Deliberately
Peer-to-peer consultation is where a lot of medical director bandwidth disappears, and where a lot of unnecessary friction gets created. The requests that actually need a peer-to-peer conversation are the ones with genuine clinical ambiguity, not every denial. Set clear criteria for when peer-to-peer is offered, staff it with reviewers who have the specialty depth for a real clinical conversation, and track how often it actually changes the outcome — that data tells you whether your initial review criteria need adjustment.
Know When to Bring in External Capacity
Internal UM teams are usually built for steady-state volume, not for specialty surges, sudden growth, or the review depth a complex case demands. The signal to bring in external review capacity isn't just volume — it's when your team is making decisions outside its specialty depth, when turnaround is slipping against regulatory deadlines, or when peer-to-peer requests are consuming more medical director time than the strategic work they were hired for.
CareReview provides physician-led utilization review and pharmacy review built for exactly these moments — surge capacity, specialty depth, and peer-to-peer support without turnaround slippage. See our Health Review and Pharmacy Review pages for the full scope.