How to Check Authorization Status
How to Check Authorization Status: The Complete Guide
Providers, families, and patients can prevent avoidable delays by understanding when prior authorization is needed for a healthcare service and how to check the request status. This guide clarifies the meaning of authorization status, where to check, what information to maintain and what to do with a request pending approval, denied or needs some documentation.
Table of Content
- Definition & Purpose of Authorization Status
- Understanding Authorization & Timing
- What Authorization Status Means
- Authorization Status Breakdown
- The Four Stages of Authorization Review
- How to Check Authorization Status
- Supporting Patients & Referral Partners
- Authorization Status & Care Settings
- Preparing to Check Authorization Status
- FAQs
Definition & Purpose of Authorization Status
Are you waiting until services can begin? Do you have doubts on whether an authorization request is received or read? Do you need to know whether extra documentation is required?
Authorization status indicates the current position of a request to the relevant payer. A request can be pending, approved, denied, expired or categorized as not needing authorization depending on the payer and service. These statuses are considered as shared prior authorization statuses at CMS, but other statuses may be utilised by any individual payer.
Monitoring position aids providers with the normal check-up of the status to provide information to patients and referral partners, respond to documentation requests, and identify outstanding requests.
Understanding Authorization & Timing
Authorization requirements vary by payer, plan, service, and patient circumstances. Some services may require prior authorization before they are provided, while others may not require it.
The status can help determine whether
- The request has been received
- The payer is still reviewing the request
- Additional information is required
- The service has been approved
- The request has been denied
- The authorization has expired
- Prior authorization is not required
For certain impacted payers, CMS requires prior authorization decisions to be communicated within seven calendar days for standard requests and 72 hours for expedited requests
What Authorization Status Means
Authorization status refers to the current stage of a payer’s review of a request for a particular healthcare service.
Common statuses include
Pending
The request has been submitted and is still being reviewed by the payer.
Approved
The payer has approved the requested service, subject to the applicable authorization terms.
Denied
The payer has determined that the request is not approved. For impacted payers, providers must receive a specific reason for certain denied prior authorization decisions.
Additional Information Required
The payer needs further documentation or information before completing the review.
Expired
The authorization period has ended or the approved authorization is no longer active.
Authorization Not Required
The requested service does not require prior authorization under the applicable payer’s requirements.
Authorization Status Breakdown
Checking authorization status involves more than simply confirming whether a request was approved. Providers should review the details associated with the authorization.
Core authorization status considerations typically include
Request Number
The authorization or reference number helps identify the specific request when communicating with the payer.
Patient Information
Patient identifiers should be verified to ensure the correct authorization is being reviewed.
Requested Service
Confirm that the status relates to the correct service, procedure, treatment, or level of care.
Submission Date
The submission date helps providers determine how long the request has been under review.
Current Status
Review whether the request is pending, approved, denied, expired, or requires additional information.
Authorization Dates
For approved requests, review the effective and expiration dates to confirm the period during which services are authorized.
Approved Services or Units
Check whether the payer approved the requested service, frequency, duration, or number of units.
Additional Documentation
Determine whether the payer has requested medical records or other supporting information before completing the review.
The Four Stages of Authorization Review
Authorization requests generally move through several stages from submission to final determination.
Step 1 – Request Submission
The provider submits the authorization request and requires supporting documentation through the payer’s approved process.
Step 2 – Payer Review
The payer reviews the request and supporting information to determine whether the requested service meets applicable requirements.
Step 3 – Status Determination
The request may remain pending, require additional information, be approved, or be denied based on the payer’s review.
Step 4 – Ongoing Authorization Monitoring
Approved authorizations should be monitored for expiration dates, remaining units, changes in services, and additional authorization requirements.
How to Check Authorization Status
The exact process depends on the payer and its available systems. Providers should use the payer’s designated portal, electronic system, or provider contact method.
Step 1: Gather Authorization Information
Keep the patient’s name, member identification number, authorization number, service requested, and submission date available.
Step 2: Access the Payer System
Log into the payer’s provider portal or applicable authorization platform. Some payers also provide electronic authorization tools through connected healthcare systems.
Step 3: Search for the Request
Use the authorization number, patient information, reference number, or other identifying information required by the payer.
Step 4: Review the Current Status
Check whether the request is pending, approved, denied, expired, or awaiting additional information.
Step 5: Review Authorization Details
If approved, verify the authorized services, effective dates, expiration date, quantity, frequency, and duration where applicable.
Step 6: Follow Up When Needed
If the request remains pending, additional information is requested, or the status cannot be located, contact the payer through its designated provider service channel and document the follow-up.
Supporting Patients & Referral Partners
Authorization delays can create uncertainty for patients, families, and referral partners. Clear communication helps everyone understand what is happening with a request.
Authorization Updates
Providers can share appropriate status updates with patients, families, and referral partners while protecting patient information.
Documentation Support
If additional clinical records are requested, the care team can identify and submit the appropriate supporting documentation.
Payer Communication
When an authorization cannot be located or remains pending beyond the expected timeframe, providers can contact the payer for clarification.
Ongoing Monitoring
Authorization status should be checked throughout the service period to prevent missed expiration dates or interruptions in approved care.
Authorization Status & Care Settings
Authorization requirements can differ depending on the payer, service, and care setting.
Prior authorization may be relevant to services provided in settings such as
- Patient's home
- Hospice settings
- Assisted living facilities
- Nursing facilities
- Community-based programs
- Other approved care settings
CMS requires certain impacted payers to provide electronic prior authorization capabilities, including functionality that allows providers to determine whether authorization is required, identify documentation requirements, and exchange authorization requests and responses. The exact process still depends on the applicable payer and service.
Preparing to Check Authorization Status
Providers and referral partners can make status checks easier by keeping authorization information organised.
Consider
- Patient name
- Member identification number
- Payer and plan information
- Authorization number
- Referral number
- Requested service
- Submission date
- Provider information
- Supporting documentation
- Expected decision timeframe
Ask questions such as
- Has the payer received the authorization request?
- What is the current authorization status?
- Is additional documentation required?
- Has the request been approved or denied?
- What services and units were approved?
- When does the authorization become effective?
- When does the authorization expire?
- What should we do if the request remains pending?
FAQs
How can I check the status of an authorization?
Providers can generally check through the payer’s provider portal, authorization system, or designated provider service channel. The specific process varies by payer.
What does pending authorization mean?
Pending generally means the payer has received the request and has not yet made a final determination. The payer may also request additional information during the review.
What should I check after an authorization is approved?
Review the approved service, authorization number, effective date, expiration date, units, frequency, and duration to ensure they match the requested care.
What happens if an authorization is denied?
Review the denial reason and determine whether additional documentation, correction, resubmission, or an appeal may be appropriate under the payer’s process. CMS requires certain impacted payers to provide specific denial reasons for prior authorization decisions.
How long does a prior authorization decision take?
For certain impacted payers, CMS requires decisions within 72 hours for expedited requests and seven calendar days for standard requests. Individual payer and program requirements may vary.
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