Tips for Getting Prior Authorization Approved in O&P

Prior authorization is often one of the most frustrating parts of orthotic and prosthetic (O&P) care. Payers require it to confirm medical necessity before approving coverage—but delays, denials, or unclear requirements can slow care and impact your cash flow. Here are practical tips to increase your chances of fast, successful approvals.

1. Know Each Payer’s Rules

Every insurance company has different prior authorization policies—and they can change without much notice. Create a payer-specific cheat sheet or checklist for your team that outlines:

• What items/services require prior auth
• Documentation requirements
• Forms or portals used
• Turnaround time expectations

2. Get Documentation Right the First Time

Medical necessity must be clearly supported. Make sure you have:

• A recent physician's order (signed and dated)
• Relevant clinical notes or chart documentation
• Functional evaluation (for prosthetics)
• Justification for the specific device and coding

Tip: Avoid generic or vague language. Use specific terms that align with the payer’s coverage policies.

3. Double-Check Coding

Using the wrong HCPCS code or mismatched diagnosis code can lead to instant denial. Verify that the codes submitted match the documentation and comply with current Medicare or private payer guidance (including PDAC verification, if applicable).

4. Submit Electronically When Possible

Many payers now offer online portals for faster, tracked submission. Electronic submissions often get processed more quickly and reduce the risk of lost paperwork.

5. Follow Up—Don’t Wait

If you haven’t received a decision within the expected timeframe, follow up. Delays are common, and a proactive call or portal check can sometimes push things along or uncover missing information.

6. Appeal When Needed

Don’t accept a denial without reviewing it. If the denial was due to missing documentation or an unclear justification, fix the issue and submit an appeal promptly. Include a strong letter explaining medical necessity, backed by documentation.

7. Keep a Log

Track every authorization request, including:

• Date submitted
• Documents provided
• Contact names (if you call)
• Response dates and status

This helps prevent lost revenue and provides useful insight into payer trends.

---

Getting prior authorization right can save time, reduce denials, and improve your patients' access to care. If you need help building better processes or managing your authorizations, contact me at lcollins@cpousa.com — we’re here to support your practice.