We check whether each service needs approval, file the request with the documentation the payer asks for, track every approval to its expiry, and appeal the denials, inside the EHR you already use.
Prior authorization
An authorization problem is decided before the patient arrives and discovered after the claim denies, when the service has already been delivered. That is what makes these denials expensive.
The service needed approval under that plan and nobody asked. The claim comes back with reason code 197, after the care was delivered.
The approval named a different code, fewer units or another site of service than what was performed.
Courses of treatment, infusions and injection series outlast their approvals. The visit after the end date is unauthorized.
A denial that a short call with the plan's reviewer could have reversed becomes a written appeal, or a write-off.
Authorization denials can be appealed, and many plans must now give a specific reason. Many are never contested.
Process
Every request follows the same six steps, and every approval is tracked against the visit it covers.
| Step | What we do | Where it usually breaks |
|---|---|---|
| Check | Confirm at scheduling whether the plan requires approval for the code, site and diagnosis | Checked after the visit, or not at all |
| Prepare | Gather the notes, imaging and treatment history the plan's criteria ask for | Request sent without the evidence the criteria need |
| Submit | File through the payer's portal or electronic channel with the right codes, units and site | Wrong code, units or place of service |
| Track | Record the approval number, dates, units and visits, and follow up on pending requests | Approval expires between visits |
| Match | Compare the codes performed with the codes approved before the claim is sent | A different code performed than approved |
| Appeal | Arrange the peer-to-peer and file the written appeal when a request is denied | Denial accepted as final |
When a denial does land, it goes into the same process as every other denial. See denial management.
2026
Since 1 January 2026, Medicare Advantage plans, Medicaid and CHIP fee-for-service programs and their managed care plans must decide standard requests within seven calendar days and expedited requests within 72 hours. Every denial must come with a specific reason, and the plans publish their prior authorization metrics each year, starting by 31 March 2026.
The same payers must run a prior authorization API from 1 January 2027. Clinicians in MIPS report a new Electronic Prior Authorization measure from the 2027 performance period.
From 1 January 2026 to 31 December 2031, selected services in Original Medicare need prior authorization, or go through pre-payment review, in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. Examples include skin and tissue substitutes, electrical nerve stimulator implants and knee arthroscopy for osteoarthritis. Medicare Advantage patients are not included.
Medicare Advantage plans must follow Medicare's national and local coverage determinations, and can use internal criteria only where Medicare's are not fully established. An approval for a course of treatment stays valid as long as it is medically necessary, and new enrollees who are mid-treatment get at least a 90-day transition.
Source: CMS-0057-F fact sheet · WISeR Model · CMS-4201-F fact sheet
Hospital outpatient
Original Medicare also requires prior authorization for certain services performed in hospital outpatient departments. The hospital submits the request, usually with the treating physician's documentation, so practices that operate there need to be part of the process.
| Since | Services |
|---|---|
| 1 July 2020 | Blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation |
| 1 July 2021 | Implanted spinal neurostimulators and cervical fusion with disc removal |
| 1 July 2023 | Facet joint interventions; CPT 64492 and 64495 were later removed from the list |
Coverage limits for facet and epidural injections are covered on the PM&R billing page.
Comparison
A process comparison, not a promise of outcome. It shows what changes in how authorizations are handled.
| Area | Before | With Quilven |
|---|---|---|
| Requirement check | Checked after the visit, when the claim denies. | Checked at scheduling against the plan's code, site and diagnosis rules. |
| Documentation | Requests sent without the notes the criteria ask for. | Requests built around the plan's criteria, with the evidence attached. |
| Tracking | Approvals on a spreadsheet, or in someone's inbox. | Approval number, dates, units and visits tracked for every patient. |
| Expiry | Treatment continues after the approval ends. | Renewals filed before the next visit falls outside the approval. |
| Code match | A different code performed than the one approved. | Performed and approved codes compared before the claim is sent. |
| Denials | Authorization denials accepted, or appealed too late. | Peer-to-peer arranged and written appeals filed inside the deadline. |
| Reporting | Authorization denials hidden inside the denial total. | Authorization denials reported by payer in Apex, so patterns show. |
Which of these applies to your practice is a question the audit answers. Request the audit.
Case study
One AR recovery engagement, at a family medicine practice in Minnesota. Shown for method. Individual results vary. One engagement is not a forecast.
We reviewed 245 claims. The rejection queue had no owner, and some claims in it had waited close to a year.
Billed charges in that queue came to roughly $40,000 to $50,000, none of it being worked.
Most of the damage started before the claim was built. Stale coverage, incorrect member IDs and skipped eligibility checks at the front desk caused 70% of the denials.
Not everything could be reopened. On most of the affected claims, a commercial payer's 90-day window had already passed with no proof of submission on file, so appeals were not possible.
What came back was about $5,500, paid on 50 to 55 claims, most of it within 45 to 50 working days.
In their words
What you have provided for me was a detailed of things that are going wrong that needed to change in our practice.
I appreciate that you did an audit and found out the root causes of a lot of my problems which are preventable.
I appreciate the professionalism, the courtesy, the knowledge.
After the audit the practice changed how it runs: eligibility verified before arrival, no more walk-ins, every patient checked the night before.
Pricing
Prior authorization is included in medical billing: 3 to 5 percent of collections with a $500 monthly minimum, the same for every specialty. You can see pricing in full.
12 to 15%
of the recovered amount
No fee on what is not recovered. Where a practice lands in the range depends on claim volume, age of the inventory, and payer mix.
3 to 5%
of collections by monthly volume
A $500 monthly minimum applies. The rate moves with monthly volume, not with headcount on your side.
$150 to $200
per payer application
$200 per application, or $150 each on larger batches. Included in the billing percentage for billing clients.
Fit
Outsourcing prior authorization does not require a system swap. We integrate with 30+ EHRs and practice management systems and work inside the one you already have. No data migration, no parallel system, no change to how your staff enters a charge or checks a patient in. If your team is trained on your current software, that training stays valid.
This matters because the usual objection to outside authorization help is that it turns into an implementation project. It does not here. Quilven is a managed service, not software. There is no proprietary platform you are asked to adopt and no license to renew, so the engagement can start on the requests already in your queue rather than after a build-out.
What you do get is visibility. Apex is our client dashboard, and it shows in real time:
Apex reads the work we are doing in your system. It is a window, not a replacement, so if the engagement ends your records and workflows are exactly where they were.
Company
Quilven is a managed revenue cycle service. Not software, not an EHR, and not a proprietary platform you have to adopt. We work inside the system your practice already uses, across 30+ integrations, with no data migration and no workflow change. Our clients are independent practices with 3 to 25+ providers.
Pricing is straightforward. AR recovery is 12 to 15 percent of the recovered amount. Medical billing is 3 to 5 percent of collections by monthly volume, with a $500 monthly minimum. Credentialing is $150 to $200 per payer application.
The entry point is a free RCM audit. It takes 3 to 5 business days and returns a line-by-line recoverable revenue estimate by payer, so the first thing you get from us is a diagnosis you can act on with or without us.
We lead with method and evidence rather than tenure. Quilven was founded in 2025 by Raief Shick and works from 159 4th Ave N, Suite 100, Nashville, TN 37219. The entity is registered in Wyoming. Reach us at (202) 490-9406 or info@quilven.com.
Fit
Independent, physician-owned practices with 3 to 25+ providers whose services need approvals: imaging, infusions, injections, surgery and therapy. Solo practices are welcome too.
Specialty rules are covered on the cardiology page for imaging, gastroenterology for capsule endoscopy and biologics, and dermatology for biologics.
It is not for hospitals managing facility authorizations.
At a glance
FAQ
Sources
Checked 17 October 2026. Coverage policies and code rules revise without much notice, so confirm the current version before you rely on one.
Next step
The audit takes 3 to 5 business days and returns a line-by-line recoverable revenue estimate by payer, plus the repeating root causes behind your denials. We only need aging totals to begin. No patient data, no contract, no obligation to work with us afterward. If your aging is healthy we will tell you that.
Answer three questions below and book a line-by-line audit of your authorizations and denials.
Pick the one that hurts most. We start there.
A round number is fine. We verify it in the audit.
Just you, or a group. Either is welcome.
No patient data. We only need aging totals to start.
(202) 490-9406 · info@quilven.com · Book 15 minutes