Prior Authorization · 6 min read · Updated October 12, 2026

How Prior Authorization Works in a Medical Practice

Prior authorization is a payer's approval of a service, procedure or medication before it is delivered. In a medical practice the work follows a set path: confirm that a request is required, gather the clinical documentation, submit it to the payer, track the response, and act on the decision. The practice's licensed clinicians supply the clinical justification. The administrative steps around it can be handled by trained staff or a remote assistant.

Who starts a prior authorization request?

The request starts in the practice. A clinician orders a service, and the practice checks whether the patient's plan requires approval for it. If it does, the practice, not the patient, normally submits the request to the payer.

That check depends on current plan rules. This is why insurance verification usually comes first: it shows whether the plan is active and whether the order is likely to need approval.

The six steps of the workflow

• Confirm the requirement. Check the payer's rules for the specific service and plan.
• Collect documentation. Gather the order, relevant notes, test results and any forms the payer asks for.
• Obtain clinical sign-off. A licensed clinician reviews the justification before anything is sent.
• Submit the request. Use the payer's portal, electronic channel, fax or phone, depending on what the payer accepts.
• Track the request. Record the reference number, the submission date and the date a decision is due.
• Act on the decision. Schedule the service if approved. If it is denied or more information is requested, route it back to the clinician.

What the payer decides and what the practice decides

The payer decides whether it will cover the service under the plan. The clinician decides what care the patient needs. Administrative staff do not make either decision. Their job is to make sure the request is complete, correctly routed and followed up on time.

Where the process usually slows down

Delays most often come from missing documents, requests sent to the wrong channel, and requests that no one follows up on after submission. Our guide to common prior authorization delays covers each cause and a practical fix.

Many payers now face federal timing rules for these requests. See what practices should know about the CMS prior authorization rule.

Where a virtual medical assistant fits

A virtual medical assistant can prepare the paperwork, submit it through your approved process, and keep a tracking log. See how a virtual medical assistant supports prior authorization and our prior authorization support service.

Related services from our team: Prior authorization support service | Insurance verification service.

Sources

• CMS: Interoperability and Prior Authorization final rule (CMS-0057-F) fact sheet