Revenue Cycle teams need reliable tracking, usable denial reasons, and clear escalation paths to turn faster payer decisions into timely care and cleaner claims.
By Vanessa Couch-Laguana, Head of RCM, LunaBill
CMS now requires certain impacted payers to send prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests. Beginning in 2026, those payers must also give a specific reason when they deny a request. These requirements are important, but a shorter decision window does not help if the provider cannot see when the clock started, whether the payer received the request, or who is responsible for the next step.
Revenue Cycle leaders should treat prior authorization as a tracked workflow with defined owners. The process begins before submission and continues until the decision, approved service, documentation, and claim all match.
Make the clock visible
Every request should have a submission timestamp, urgency level, payer confirmation, expected response date, and assigned owner. An acknowledgement that the payer received a request is not the same as a decision. If teams cannot distinguish the two, accounts may sit untouched until the date of service is at risk.
Automation can monitor portal activity, incoming messages, and work queues. It can also place a payer call when a response is overdue or the portal does not provide enough information. The result should return to the same record so staff can see what happened without rebuilding the history.
Turn denial reasons into action
A specific denial reason is useful only when it reaches the right person quickly. Missing clinical documentation belongs with the clinical or Utilization Management team. A coverage or eligibility issue may belong with Patient Access. A coding discrepancy requires qualified coding review. The workflow should route the issue based on the reason and preserve the payer’s wording.
Automation can classify the response, attach supporting information, and prompt the next task. It should not decide medical necessity or change coding. Those decisions require human judgment and a clear audit trail.
Escalate patterns instead of repeating calls
One overdue request may need account-level follow-up. Ten overdue requests for the same payer and service line point to a broader issue. Automated monitoring can group those accounts, show the oldest and highest-dollar cases, and prepare the facts for payer escalation or a joint operating committee discussion.
This reduces repeated calls that produce the same answer. Staff can focus on exceptions, clinical questions, and situations where a payer response does not match the submitted documentation.
Measure whether the process is working
Leaders should monitor decision turnaround time, overdue requests, requests for additional information, denial reasons, resubmissions, missed dates of service, and the percentage of accounts requiring human review. Review urgent or high-dollar exceptions immediately, trends at least biweekly, and overall performance monthly.
Faster payer decisions create an opportunity. The operational benefit appears only when the organization can capture the response, assign the next step, and resolve the exception before it affects care or reimbursement.
