Prior authorization for provider organizations
Get the authorization before the patient is on the schedule.
PriorPilot works inside your EHR. It finds which orders need authorization, builds the request from the chart, submits it to the payer, and follows up until there is a decision. Your team reviews and signs every request.
Works with FHIR R4, SMART on FHIR, CDS Hooks, Da Vinci CRD, DTR and PAS, X12 278, and NCPDP ePA.
Authorization queue
| Patient | Service | Payer | Status | Due |
|---|---|---|---|---|
| M. Alvarez | MRI lumbar spine 72148 | Commercial PPO | Ready to sign | Today |
| R. Chen | Pembrolizumab infusion J9271 | Medicare Advantage | Submitted · API | 72 h |
| D. Okafor | Total knee arthroplasty 27447 | Medicaid MCO | Info requested | Tomorrow |
| S. Patel | Cardiac PET 78492 | Commercial HMO | Approved | — |
| J. Murphy | Home sleep test 95806 | Commercial PPO | Not required | — |
Why it matters
Prior authorization takes a day of staff time every week, per physician.
Most requests still go through portals, phone, and fax. Every delay pushes back care, and every missed authorization becomes a denied claim.
40
prior authorizations per physician each week, taking 13 hours of physician and staff time.
AMA 2025 PA physician survey95%
of physicians report that prior authorization delays access to necessary care; 26% report a serious adverse event.
AMA 2025 PA physician survey65%
of medical prior authorizations still go through web portals, phone, or fax. Only 35% are fully electronic.
CAQH Index 202452.8M
prior authorization determinations in Medicare Advantage in 2024; 80.7% of appealed denials were overturned.
KFF analysis, 2026What PriorPilot handles
The whole authorization, not just the form.
01
Authorization check
Flags at order entry whether the payer requires authorization for that code, plan, and site of care, and what documentation they expect.
02
Eligibility & benefits
Confirms active coverage, the responsible plan, and any delegated utilization-management vendor before work starts.
03
Request preparation
Pulls diagnoses, prior treatment, imaging, and notes from the chart into the payer's form or questionnaire, with sources attached.
04
Submission
Sends through the payer's API, the clearinghouse, the payer portal, or fax, depending on what each payer accepts.
05
Follow-up
Tracks every open request, answers requests for more information, and schedules peer-to-peer calls when needed.
06
Denials & appeals
Reads the denial reason, finds the missing evidence, and drafts the appeal letter for your team to finalize.
One request, start to finish
What a morning looks like with PriorPilot.
- 8:02 am
Dr. Lee signs an order for a lumbar MRI in the EHR.
- 8:02 am
PriorPilot checks the patient's plan and returns a note in the order: authorization required, records look complete.
- 8:06 am
The request is drafted: diagnosis, seven weeks of physical therapy, neuro exam findings, each linked to the note it came from.
- 9:40 am
The prior auth coordinator reviews the draft, edits one line, and signs.
- 9:41 am
PriorPilot submits through the payer's prior authorization API and stores the tracking number.
- Next day
Approval arrives. The authorization number is written back to the order and the scheduler is notified.
Request · MRI lumbar spine (72148)
Payer criteria: Advanced imaging, lumbar spine
- ✓
Radicular low back pain for 6+ weeks
Problem list, onset Jul 28
- ✓
Physical therapy tried for 6+ weeks
PT discharge note, Sep 2: “7 weeks, no relief”
- ✓
Neurologic deficit on exam
Clinic note, Sep 9: L5 weakness 4/5
- ✓
No lumbar imaging in last 12 months
No prior MRI or CT found
Who uses it
Less chasing for the people who do this work every day.
Prior auth coordinators
One work queue across payers instead of a dozen portals. Drafts arrive ready to review, not blank forms to fill.
Practice and RCM leaders
Turnaround, first-pass approval, and denial reasons by payer and service line, updated daily.
Physicians
Fewer interruptions and peer-to-peer calls. Requirements show up while the order is still open, not after the patient leaves.
IT and integration teams
Standard FHIR and SMART on FHIR integration, read-only to start, with a clear list of scopes and data flows.
Customer onboarding
How a new practice goes live in about five weeks.
Every new customer starts read-only and in shadow mode, so your team sees PriorPilot's drafts before anything is sent to a payer.
Weeks 1–2
Connect
SMART on FHIR app registration, read-only FHIR access, payer list and volume review.
Weeks 3–4
Shadow
PriorPilot drafts every request alongside your team. We compare drafts to what was actually submitted.
Week 5 on
Go live
Turn on submission payer by payer, starting with the highest-volume service line.
What we report
The numbers we track with every customer.
Turnaround
Order signed to request submitted, and submitted to decision.
First-pass approval
Requests approved without a request for more information.
Staff time per request
Minutes of coordinator work, measured from the work queue.
Write-offs avoided
Services that would have gone out without a valid authorization.
The rules are changing
Payers have new deadlines. Your workflow should be ready for them.
Since January 2026, Medicare Advantage, Medicaid, and federal exchange plans must decide urgent requests within 72 hours and standard requests within 7 days. By January 2027 they must offer a prior authorization API. PriorPilot already speaks the standards those APIs use.
CMS-0057-F, Da Vinci, and X12, explained
A plain-language timeline of what changes and when, with links to the rules.
Read the overview →
FAQ
Common questions
Which EHRs do you work with?+
Any EHR that supports FHIR R4 and SMART on FHIR app launch, which includes the major ambulatory and hospital systems. Where CDS Hooks is available we check requirements at order signing; otherwise we read new orders from the EHR's order feed.
What if a payer doesn't have an API yet?+
Most still don't. PriorPilot uses the clearinghouse (X12 278) where it can, then the payer's portal, then fax. Responses from every channel come back into the same work queue.
Who makes the decision to submit?+
Your staff. PriorPilot prepares the request and shows where each piece of evidence came from. A coordinator or clinician reviews and signs before anything goes to the payer.
How is patient data handled?+
We sign a BAA, keep each customer's data in its own encrypted environment, log every access, and never use your data to train models for anyone else. See the security page for details.
Do you handle pharmacy prior authorizations?+
Yes, for medications billed under the medical benefit, such as infusions, and through NCPDP ePA for pharmacy-benefit drugs.
See it on your own orders.
Bring one service line and your top payers. We'll show you the drafts PriorPilot would have built last week.