Eligibility verification and prior authorization
Coverage, benefits and authorizations confirmed before the patient arrives, so coverage problems are caught before the claim is created.
Many of the denials a practice sees were decided at the front desk. A plan that terminated at the end of last month, a secondary listed as primary, an HMO referral that was never obtained, or an MRI scheduled without an authorization all lead to denials that take far more time to fix than they would have taken to prevent.
SFA Solutions verifies coverage before scheduled visits using electronic 270/271 eligibility checks, payer portals and calls when needed. We confirm active coverage on the date of service, network status, primary and secondary order, copay, coinsurance and remaining deductible, and whether a referral or authorization is required. For services that need prior authorization, we submit the request with the supporting clinical documentation your provider has already written, track it to a decision, and record the authorization number, approved units and dates. Your front desk gets a checked schedule with problems flagged early.
Who this is for
This service suits practices with heavy authorization requirements, such as radiology, cardiology, oncology, gastroenterology, orthopedics, physical therapy and behavioral health, along with high-volume primary care and urgent care practices where coverage changes often. It also helps small offices where the front desk does not have time to sit on hold with payers.
Related services
What our eligibility verification & prior authorization service covers
Pre-visit eligibility checks
Coverage verified for upcoming appointments, with inactive plans and payer changes flagged to your front desk before the visit.
Benefits breakdown
Copay, coinsurance, remaining deductible and visit limits recorded so your staff can give accurate cost estimates.
Coordination of benefits
Primary and secondary order confirmed, including Medicare Secondary Payer situations, to avoid CO-22 denials.
Prior authorization requests
Requests submitted through payer portals or by fax with the provider's existing documentation, then tracked to approval.
Authorization tracking
Auth numbers, approved CPT codes, units and date ranges logged, with alerts before visits run out or dates expire.
Referral checks
HMO and POS plan referral requirements confirmed so specialist visits are not denied as out-of-network or unreferred.
How we deliver it
Setup
We get access to your schedule, PM system and payer portals, and list which of your services commonly need authorization by payer.
2 to 3 days before visits
Eligibility and benefits are checked for scheduled patients, and any issue is sent to your staff with a clear next step.
When an auth is needed
We submit the request, follow up until the payer decides, and update your schedule with the result.
Monthly
We report eligibility and authorization denials, turnaround times by payer, and any service whose auth rules changed.
What we check and the denial it helps prevent
| Check | How we verify it | Denial it helps prevent |
|---|---|---|
| Active coverage on the date of service | 270/271 eligibility response or payer portal | CO-27 (expenses incurred after coverage terminated) |
| Primary vs. secondary payer | Eligibility response, patient confirmation, Medicare MSP rules | CO-22 (may be covered by another payer) |
| Prior authorization on file | Payer auth lookup and our authorization log | CO-197 (precertification or authorization absent) |
| Auth number matches service and provider | Compare approved CPT codes, units, dates and NPI | CO-15 (authorization number missing, invalid or does not apply) |
| Network and referral rules | Plan type, PCP assignment and referral on file | CO-242 (services not provided by network or primary care providers) |
| Patient cost share | Copay, coinsurance and deductible remaining | Surprise PR-1, PR-2 and PR-3 balances that patients dispute later |
Eligibility Verification & Prior Authorization for your specialty
We bill for 28+ specialties. These are the ones we work with most.
Nurse Practitioner billing
Billing for NP-led and physician-NP practices, from the 85% Medicare rate and incident-to rules to split/shared visits and getting each NP credentialed under the right NPI.
Learn moreInternal Medicine billing
Billing for internists who manage complex, chronic patients, with E/M levels, wellness visits and care management codes captured when the documentation supports them.
Learn moreOphthalmology billing
Eye exam codes, refraction, diagnostic testing, cataract globals and high-cost injectable drugs all follow their own rules. Ophthalmology is one of the specialties we bill most often.
Learn moreQuestions about eligibility verification & prior authorization
How far ahead do you verify eligibility?
Usually two to three business days before the visit, so there is time to reach the patient if coverage has changed. Same-day and walk-in visits are checked as they are added to the schedule.
How long do prior authorizations take?
It depends on the payer and service. Under the CMS Interoperability and Prior Authorization Final Rule, starting in 2026 Medicare Advantage, Medicaid, CHIP and marketplace plans must generally decide standard requests within 7 calendar days and expedited requests within 72 hours. Other commercial plans follow their own timelines and state laws.
Can you get an authorization after the service was done?
Some payers allow retro authorization within a short window, often for urgent or emergency situations. Many do not. That is why we check authorization requirements before the visit instead of after a CO-197 denial.
Do you call patients about their coverage?
We send your staff a clear note when coverage is inactive or a referral is missing, and we can contact patients about insurance updates if you want us to handle that step.
Does this help with patient cost estimates?
Yes. Copay, coinsurance and remaining deductible are recorded with each check so your staff can collect at check-in. For uninsured or self-pay patients, we can help prepare good faith estimates required under the No Surprises Act.
Start with a free review
Tell us a little about your practice. We will look at where eligibility verification & prior authorization is costing you money today and walk you through what we find.
- No commitment
- Reply from an RCM specialist, typically within one business day
- No patient records needed to start
Get a free review
An RCM specialist typically replies within one business day.