Most U.S. hospitals and clinics lose revenue, staff hours, and patient goodwill to prior authorization friction. The AMA’s prior authorization survey finds practices complete roughly 40 authorizations per physician per week, consuming about 13 hours of staff time, while 94% of physicians report care delays. Meanwhile, CMS-0057-F now holds payers to 72-hour expedited and 7-day standard decisions. RCMGen’s prior authorization services close every one of those gaps end to end.
Our authorization specialists work daily across Medicare, Medicare Advantage, Medicaid, managed Medicaid, and every major commercial payer. As a result, our workflow consistently secures 96% or more of authorizations before the date of service and keeps authorization-related denials under 2% of total denials, well below the industry pattern documented across payer transparency reporting.
From the moment a service is ordered to the day the approved authorization attaches to the claim, our prior authorization workflow runs continuously. Our operations teams screen schedules 72 hours ahead, assemble clinical documentation, submit through payer portals and EDI 278 transactions, and follow every request until determination. Moreover, every request moves through payer-specific playbooks built from real approval outcomes, so each submission is backed by the exact clinical criteria the payer applies rather than guesswork.
Authorization requirement screening
Every scheduled service is checked against current payer authorization lists 72 hours ahead, so no patient arrives without a required approval in place.
Clinical documentation assembly
Chart notes, imaging, labs, and medical necessity evidence are compiled to the payer’s published criteria before the request is submitted.
Submission and determination tracking
Requests transmit via payer portals, fax, and EDI 278, with every pending determination tracked against CMS-0057-F decision timelines.
Peer-to-peer coordination
Clinical reviews are scheduled around your physicians’ availability, with case summaries prepared so each call takes minutes, not hours.
Expedited and urgent requests
Urgent cases route through expedited channels with 72-hour decision tracking, escalation scripts, and state-mandated urgency criteria applied.
Retro authorization recovery
Services rendered without authorization are recovered through retro requests, urgent and emergent waivers, and state continuity-of-care rules.
Prior authorization benchmarks we operate against
The dashboard below shows the U.S. industry benchmarks our prior authorization workflow is engineered to outperform, sourced from the AMA, CAQH, and CMS transparency reporting. Each indicator marks the median, with the blue zone showing our internal target range across hospital, clinic, and physician group accounts.
Benchmark sources: AMA Prior Authorization Physician Survey 2025, CAQH Index 2025, CMS-0057-F payer reporting 2026.
Authorization types we secure daily
Authorizations behave differently depending on the service line and payer. Therefore, we operate dedicated workflows for the nine authorization categories that carry the largest volume and denial exposure across U.S. hospitals, clinics, and physician groups. Each category has a specialist team, payer-specific clinical criteria checklists, and decision-timeline tracking aligned to CMS-0057-F and state mandates.
Advanced imaging (MRI, CT, PET)
Radiology benefit manager submissions, appropriate-use criteria documentation, and clinical indication matching to payer imaging policies.
Surgical procedure authorizations
Pre-surgical approvals with CPT-specific criteria, site-of-service requirements, and assistant surgeon and implant authorizations handled together.
Specialty pharmacy and infusion
Buy-and-bill and pharmacy benefit authorizations, step therapy documentation, and J-code unit validation against payer drug policies.
Behavioral health authorizations
Initial and concurrent reviews, level-of-care criteria, and state parity rules applied across inpatient, IOP, and outpatient programs.
Cardiology procedure authorizations
Cath lab, electrophysiology, and device approvals with appropriate-use criteria and registry documentation assembled per payer.
Oncology treatment authorizations
Chemotherapy regimens, radiation plans, and pathway compliance documentation matched to payer oncology policies and NCCN guidance.
Durable medical equipment
DME approvals with face-to-face documentation, medical necessity certificates, and rental-versus-purchase rules applied per payer.
Therapy and rehabilitation
PT, OT, and speech visit authorizations, progress documentation, and visit-count tracking so care never outruns the approval.
Inpatient admission and concurrent review
Admission notifications, clinical reviews, length-of-stay extensions, and discharge planning coordination with payer case managers.
Inside a single authorization work cycle at RCMGen
Authorization work does not pause for nights, weekends, or U.S. federal holidays. As a result, every 24 hours your requests move through the cycle below, anchored to Central Time so your scheduling team always knows what to expect when they log in.
Overnight schedule screening
The next 72 hours of scheduled services are screened against current payer authorization lists, and every required request is opened and queued.
Submission and documentation assembly
Clinical documentation is compiled, requests transmit via portal, fax, and EDI 278, and your authorization status ledger is delivered before 8 AM EST.
Payer follow-up and peer-to-peer
Pending determinations are chased, peer-to-peer reviews are scheduled and prepped, and urgent cases escalate during U.S. payer business hours.
Status reconciliation and next-day prep
Approvals attach to accounts, denials route to appeal queues, KPI dashboards refresh, and tomorrow’s screening queues are prioritized overnight.
Why hospitals and clinics choose RCMGen for prior authorization services
Most authorization vendors compete on price per request. RCMGen competes on authorizations secured before the date of service, turnaround speed, and auth-denial elimination. Our authorization team is built around senior specialists with payer-specific clinical criteria expertise, not call-center staff reading scripts. Additionally, our internal Intelligence Hub tracks payer authorization list changes inside a 72-hour refresh window, so the request you submit on Friday reflects the criteria the payer published on Tuesday.
Furthermore, we operate natively inside Epic, Oracle Health (Cerner), Athenahealth, eClinicalWorks, NextGen, Meditech, AdvancedMD, Allscripts, and dozens more, so there is zero disruption to your existing scheduling workflows.