Prior Authorization Process Flow Chart: Decisions, Owners and Records

The example below is an administrative training map for a planned medical item or service. It is not a clinical decision tree, a universal payer protocol, an emergency-care pathway or a drug authorization guide. Use the relevant plan instructions and your organization's approved procedures to adapt it.

Follow the administrative process map

This text version provides the complete flow and can be used during a team walkthrough. The labels describe the proposed operating record, not a completed test of a particular organization's process.

An arrow to the next workflow does not guarantee coverage, payment or readiness for care. It means the authorization team has recorded its disposition and handed the next task to the appropriate owner.

Check the requirement and preserve its source

Begin with the ordered item or service and the relevant patient-plan context. The person assigned to the check should record which payer source was used, when it was checked and what it said about the requirement. Do not assume a requirement for one plan applies to every product from the same insurer.

If the instruction is unclear or sources conflict, keep the uncertainty visible and assign clarification. "Not found" is different from confirmed not required. The map therefore gives uncertainty its own path back to the requirement check.

CMS's electronic prior authorization overview describes electronic access to coverage and documentation requirements, submission and tracking. That is the relevant administrative work. Availability and implementation still need to be checked for the payer and workflow in use.

For program-specific implementation context, use the CMS provider operations checklist. This flow chart does not assign a payer API deadline to provider offices.

Prepare the record without inventing clinical content

Link the request to the existing order and collect the information requested through the applicable process. If a required item is missing, assign it to someone able to supply it. Keep an administrative document request separate from a question requiring clinical judgment.

Do not have the flow chart choose medical necessity, urgency or a treatment alternative. If the case requires a clinical decision, the next owner should be an appropriate clinician operating under the organization's process. The coordinator records that handoff and follows its return.

Use a preparation record with these fields:

These fields are a suggested workflow template, not a declaration that every payer requires the same packet.

If your team loses context between preparation and submission, book a demo to walk through that handoff. Use a synthetic request or deidentified field list to show the evidence the team needs to retain.

Submit, retain evidence and distinguish the response

Use the accepted submission route and save the available confirmation or request identifier. Keep the transmission evidence separate from the substantive payer response. A successful send does not establish approval.

For impacted payers' Prior Authorization API responses under CMS-0057-F, CMS's API FAQ identifies three outcomes: approval with its ending date or circumstance, denial with a specific reason, or a request for additional information. The example map uses those distinctions while retaining a separate operational state for no response yet.

Assign a follow-up owner at submission, not after a request becomes difficult to locate. Record the applicable timing source and follow-up instructions. Do not assume that one clock governs every payer, service and response type. The separate prior authorization timing guide addresses that question in more detail.

For daily queue management, prior authorization tracking covers the record that lets a team find the next action.

Route each outcome to the right human action

For an approval, preserve the authorization reference and the details supplied by the payer, including relevant limits or ending conditions. Route the record to the next local workflow rather than making the chart claim that approval settles every scheduling or payment question.

For an additional-information request, capture exactly what is being requested. Assign the item, retain the response reference and connect the next submission to the original request. Do not mark a case denied merely because information is still requested.

For a denial, preserve the notice and reason. The responsible person should determine the next action using the applicable process. A correction, reconsideration, peer-to-peer discussion and appeal are not a universal fixed sequence. The map should not automatically choose one based on a short category label.

CMS's final-rule fact sheet describes specific denial-reason requirements for impacted payers and explicitly distinguishes the rule's scope from drug authorization. Keep that scope with any rule statement. The denial-reasons guide owns the more detailed analysis.

Requests involving expedited handling or services already delivered need the relevant approved process and human oversight. They should not be routed by a generic chart directly to an assumed appeal sequence, patient bill or write-off.

Use the map in a team walkthrough

Choose a hypothetical planned-service request and have staff identify who owns every box. Stop at each arrow and ask what evidence proves the handoff happened. Then repeat the exercise with missing information and with a payer response that requires human interpretation.

Record where the map cannot answer a question. Replace general labels with the team's confirmed role names and add the relevant instruction references. Keep those local details dated and assign someone to maintain them when a plan or process changes.

The walkthrough should test continuity of the record. Can another staff member find the request, understand the latest response and identify the next action? A diagram is useful when it exposes a missing owner, even before any technology changes.

Where Linear Health fits

Evaluate prior authorization automation against the administrative handoffs in this map: preparation, submission evidence, response tracking and assigned exceptions. Ask a demonstration to preserve the distinction between an automated task and a decision that still belongs to the payer or an authorized human.

Book a demo to map your authorization team's handoffs. Bring the source instructions and the roles involved so the discussion can stay specific to the workflow you actually operate.

Frequently asked questions

Sources

Sources accessed October 14, 2026. CMS pages describe CMS's own rules, FAQs and program materials.

• CMS: Electronic Prior Authorization overview
• CMS: Prior Authorization API FAQ
• CMS: Interoperability and Prior Authorization Final Rule CMS-0057-F fact sheet