On this page
- What is prior authorization automation?
- A complete request, built to that payer's requirements
- Followed until the determination is back
- Where the answer lands: writeback to your PMS
- Dental and medical: check procedures and drugs separately
- What stays with your team
- Rolling out across a group
- A selection checklist for multi-location groups
- Related reading
What is prior authorization automation?
Prior authorization automation is software that prepares, submits and follows up on the approvals a payer requires before treatment, without a person rebuilding each request by hand. For one office it saves a few hours a week. For a multi-location group it is a different problem: dozens of payers, each with its own requirements, several practice management systems, and a central team that needs every office's requests handled the same way.
Prior authorization software a group chooses has to answer four questions well: is the request complete when it goes out, is it followed until the payer answers, where does the answer land, and what is left for your team. This guide works through each one, then what to check when a vendor says it covers dental and medical.
A complete request, built to that payer's requirements
Most delays start with a request the payer cannot decide on: a missing radiograph, the wrong code, a narrative that does not address the payer's criteria. The request then comes back for more information, and treatment waits.
Software worth evaluating assembles each request to the requirements of the payer it is going to:
- Procedure codes for the planned treatment, and the tooth or site where it applies
- Attachments the payer asks for: radiographs, periodontal charts, clinical notes
- A clinical narrative written to that payer's criteria, not a generic template
Ask where the requirements come from. A tool that uses one checklist for every payer will send incomplete requests to the payers that ask for more. It also helps when the request starts from insurance verification: verification can already tell you whether a procedure needs pre-authorization, so the request is started before the appointment, not after the payer refuses the claim.
Ventus assembles each request to the payer's requirements, with codes, attachments and a narrative, on the same payer intelligence layer that runs insurance verification for 300+ payers.
Ventus for multi-location groups
Tend removed 50% of its outsourced verification load in two months across 33 locations.
Book a DemoFollowed until the determination is back
A submitted request is not a finished one. Payers take time, ask for more information, or leave a request pending. Someone has to keep checking.
Ask two questions:
- Who follows up? The software should track every request until the payer returns a determination, not only submit it.
- What happens when information is missing? A request that needs something not in the chart should go to a person with everything already assembled. It should not be guessed or left pending.
Where the answer lands: writeback to your PMS
A determination that sits in a vendor dashboard is only half done. The front desk and the treatment coordinator work in the practice management system, so the answer and its reference number need to be there before the patient is scheduled.
Ask three questions about writeback:
- Which systems? Ventus writes back into Dentrix Ascend, Dentrix Enterprise, Open Dental and Denticon, and into ModMed for specialty care. Because the agent works through the system's interface, writeback does not depend on a vendor API.
- What gets written back? There is no fixed list. It is configured for each customer: the determination, the reference number, notes and the documents that were sent.
- Is it live? Ask for a customer running writeback in your PMS today, not a roadmap slide.
Dental and medical: check procedures and drugs separately
Groups that bill both dental and medical plans, such as oral surgery, need one workflow for both. Otherwise a single case is split across two tools. When a vendor says it covers "prior authorization," ask separately about:
- Dental procedure pre-authorization, such as implants, crowns and periodontal treatment
- Medical procedure authorization
- Drug and biologic prior authorization, which is a different process with different requirements
Ventus handles dental procedure pre-authorization and medical procedure authorization in one workflow. Drug and biologic prior authorization is not supported.
What stays with your team
The honest measure of automation is what a person still touches. Clinical decisions stay with your providers. The work that should leave your team is the assembly, the submission and the follow-up. When a case needs information that is not in the chart, it should reach a person with the request already assembled.
Two things not to expect from any vendor: a published approval rate that applies to your payers (check it on your own volume during a pilot) and a promise that every payer answers on the same schedule.
Rolling out across a group
Rollout should be one central setup, not a project for each office. The group provides written authorization, business associate agreements and its own payer credentials where an account has to belong to the practice. Expect a multi-location group to be live in about a month. A payer not yet covered goes live in about a week.
Your payers. Your systems.
One central setup. Multi-location groups go live in about a month.
Book a DemoA selection checklist for multi-location groups
| What to verify | Why it matters | What to ask for |
|---|---|---|
| Requests built to each payer's requirements | One checklist for every payer sends incomplete requests | A sample request for one of your payers, with its attachments |
| Tracking to a determination | Submitted is not the same as decided | Who follows up, and how pending requests are escalated |
| Hand-off when information is missing | Guessed requests come back or get denied | What a person receives when a case needs them |
| Writeback to your PMS | Your team works in the PMS, not a vendor dashboard | A live customer on your PMS, and what they write back |
| Dental and medical in one workflow | Cases billed to both plans should not be split | Confirm both run in the same queue, and whether drugs are in scope |
| Connection to insurance verification | Verification already knows which procedures need sign-off | Whether requests start from verified benefits |
| Central rollout | Setting up each office separately does not work past ten locations | What the group must provide, and who registers payer portals |
Related reading
- The workflow page: Prior Authorization
- Where requests start: Insurance Verification
- What a payer intelligence layer is, and how it differs from an RCM platform
- Integrations: Dentrix · Open Dental
- After the determination: Claim Submission