Prior Authorization Best Practices For Surgical Practices

Know Which Services Need It

Keep a current list of authorization requirements by payer and procedure. Traditional Medicare requires prior authorization for certain hospital outpatient services, a demonstration for the same services in some ambulatory surgical centers in ten states, and the WISeR model's selected services in six states. Medicare Advantage and commercial plans publish their own lists and update them often.

Build A Complete Request

• CPT and ICD-10-CM codes for every planned procedure and level
• The site of service and the facility
• Clinical notes showing symptoms, duration and failed conservative treatment
• Imaging and test results named in the payer's policy
• Photographs where the policy requires them

Decision Timeframes

Under the CMS Interoperability and Prior Authorization final rule, starting January 1, 2026, Medicare Advantage plans, Medicaid and CHIP programs and certain other payers must decide expedited requests within 72 hours and standard requests within seven calendar days, and give a specific reason for any denial. Requests that miss those timeframes should be escalated.

Match The Claim To The Authorization

Before billing, compare the operative note to the authorization: codes, levels, site of service and dates. If the procedure changed in surgery, contact the plan to update the authorization as soon as possible.

When A Request Is Denied

Ask for a peer-to-peer review when the plan offers one, and file an appeal with any missing documentation the denial identifies. Track denials by payer and reason to see which requirements need to be built into the request template.