Why Prior Authorization Matters
Prior authorization denials are consistently among the top one or two reasons for claim denials. Payers are strict about enforcement, and most do not allow retroactive authorizations.
What Prior Authorization Checks Should Answer
A useful prior authorization workflow gives staff a clear answer on authorization requirements, including:
- Does the payer require prior authorization — for the initial evaluation, the treatment visits, or both? Or is authorization required only after a certain number of visits?
- Is a referral required? Some plans require a physician referral.
- Do visit limits affect the requirement? A patient may be allowed a set number of visits before additional authorization is needed.
- What documentation is needed? Medical-necessity notes, initial evaluations or progress notes, or signed documentation from the therapist and the patient.
Why Therapy Authorization Rules Are Easy to Miss
Therapy clinics operate across episodes of care, not one-off visits. Requirements can change as visits accumulate, as plans renew, or as a patient moves from evaluation to follow-up care.
Eligibility Alone May Not Show the Requirement
A standard eligibility response can confirm active coverage without making authorization requirements obvious. Staff still need a way to find out about authorization rules before treatment starts.
Visit Counts Can Trigger New Requirements
Some plans allow a set number of visits before additional review is needed. Others require approval before the first visit or after the evaluation.
Referrals and Authorizations Overlap
A patient may need a referral, a prior authorization, or both. Treating these as separate manual checks creates more room for staff to miss a requirement.
How Prior Authorization Software Helps
A prior authorization tool should:
- Determine whether and when prior authorization is required.
- Submit the required request on the clinic's behalf.
- Obtain the authorization and return the result to the EMR.
- Flag issues, such as a required peer-to-peer review, for the clinic.
What to Look for in a Therapy-Specific Workflow
Therapy clinics should evaluate prior authorization workflows against the requirements of PT, OT, and ST treatments.
Discipline-Aware Rules
The workflow should account for differences between PT, OT, and ST — a payer rule for one discipline may not apply to another.
Visit-Limit Awareness
Staff need to know whether visits are capped, how many remain, and whether an authorization extension is needed after a threshold.
Eligibility and Estimate Integration
Authorization context should sit alongside eligibility verification and patient estimates. If it is separate, staff have to reconcile multiple sources manually.
Exception Visibility
If a denial occurs or a peer-to-peer review is needed, the software should immediately alert clinic staff.
The Practical Goal
Prior authorization work should happen early enough to prevent the denial. When staff know what the payer requires before the patient arrives, they can act before treatment starts and avoid avoidable write-offs.
How Wiz Health Solves This
Wiz Health treats prior authorization as part of one connected workflow with eligibility and patient estimation — not a manual process staff have to run separately for every patient and every discipline.
Knowing whether authorization is required
Wiz Health checks whether a payer requires prior authorization — for the initial evaluation, treatment visits, or after a visit threshold — before the patient's first appointment.
Referrals and authorizations overlapping
Referral and authorization requirements are checked together, so nothing falls into the gap between two separate manual processes.
Visit-limit tracking
Visit counts are tracked automatically against payer limits, with alerts before a threshold triggers a new authorization requirement.
Submitting and retrieving authorizations
Wiz Health submits the request, retrieves the determination, and writes the result directly back into the EMR.
Catching exceptions like peer-to-peer reviews
Peer-to-peer requirements and other exceptions are flagged to staff immediately, not discovered weeks later after a denial.
Proven results
By catching authorization requirements before treatment starts, clinics on Wiz Health prevent up to 60% of the denials that would otherwise delay payment or become write-offs.
