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Authorization and Getting Paid, lesson 1 of 4
Prior Authorization Is the Skill the Practice Runs On
For a lot of work, approval has to come before you start, and the practices that do well at this are not the ones with better dentistry. They are the ones whose submissions answer the reviewer's question without a phone call. That is a learnable skill and it is worth more than any software.
- What it is. Approval from the program or plan before treatment
- What decides it. Whether your documents show the need
- Most common failure. An image that does not show what you say it shows
- Build. A template per procedure, so nothing is left out
What the Reviewer Is Actually Doing
A reviewer is deciding whether the record in front of them supports the treatment being requested under the program's own criteria. They are not deciding whether you are a good dentist and they are not usually looking for a reason to say no.
They see only what you sent. Everything you know from having the patient in the chair, the history, the way the tooth sounded, the thing the patient said about the pain, is invisible unless it is written down.
So the question to ask before sending is not whether the treatment is right. It is whether somebody who has never met this patient could reach your conclusion from these documents alone.
The Failures That Come Back Most Often
Images that do not show the thing being claimed. A film taken at the wrong angle, cut off at the apex, or too dark in exactly the region the argument rests on. If the image does not show it, the record does not say it.
A narrative that describes the treatment rather than the need. The reviewer already knows what you want to do. What they need is why this patient needs it now.
Missing history. How long, what has been tried, what changed. These are short sentences and they carry most of the weight.
Inconsistency between the chart, the narrative and the image. Two documents that disagree will fail even when both describe a genuine need.
Submitting so It Goes Through the First Time
Build a template for each procedure you request regularly. What images, what measurements, what history, in what order. The template is the institutional memory, and it means a new team member submits like an experienced one.
Write the narrative as if to a colleague who is not in the room. Short sentences, the finding, the duration, what was tried, what happens without treatment.
Have one person review before sending, even briefly. The person who prepared it cannot see what is missing, because they have the patient in their head.
Track your own approval rate by procedure. A procedure that comes back more often than the others has a template problem, not a luck problem, and you can fix a template.
When It Comes Back
Read what it actually says before resubmitting. A request for more information and a denial on criteria need completely different responses, and sending the same packet again answers neither.
If the criteria genuinely are not met, saying so to the patient early is better than a second submission that fails and costs another few weeks of their time.
Keep the ones that came back and what fixed them. That file becomes the most valuable training material in the practice, because it is made of your own cases.
Before You Spend a Dime
Which procedures need approval first?
That list is set by your state program or the plan, and it changes. Get the current list from them and keep it where the treatment coordinator can see it.
How long does a decision take?
Timeframes are set by the program and differ by state and by urgency. Ask for the standard they hold themselves to, and schedule against that rather than against hope.
Can we start treatment while we wait?
Starting work that needed approval before it began is one of the more expensive mistakes available here. Confirm the rule with your program before making it a habit, and treat emergencies as their own question.
Next Problem to Solve
- Getting Paid by Denti-Cal Without Losing a MonthNext in the course. How to cut denials on Medi-Cal dental claims, which ones are worth appealing, and the front desk habits that decide both.
- A Denial Is Almost Always a Document ProblemRelated. How to read a denial, sort the ones worth reworking from the ones that are telling you something, and stop the same denial from arriving again next month.
- When the Right Treatment Is Not the Covered TreatmentRelated. What to do on the day the plan a patient needs and the plan the program will pay for are not the same, without either misleading the patient or quietly lowering your standard.