Inside the payer: what happens after you submit

2 min read

From the practice side a submitted authorization is a black box that eventually emits a decision. It is not a black box. It is a pipeline with recognisable stages, and knowing which stage a request is sitting in is the difference between usefully intervening and calling to be told it is still in review.

#The stages

Intake and validation
Is the member real and active, is the provider in the file, are the required fields present. Failures here return quickly and are not clinical. If you were rejected within minutes, it was this.
Requirement check
Does this service actually need authorization under this plan. Some requests are approved here simply because no review was required.
Automated criteria screening
Increasingly, structured data is matched against criteria automatically. A request that clearly meets criteria can be approved without a human. This is where fast approvals come from, and it is also why structured, complete requests get answered faster than scanned documents.
Clinical review by a nurse
A nurse reviewer applies the criteria set. Critically, in most plans a nurse reviewer can approve but cannot deny. If the criteria are met the request is certified here. If not, it escalates.
Physician review
An adverse determination on medical necessity generally requires a physician. This is where denials are made, and it is the stage a peer-to-peer discussion addresses.

The asymmetry worth knowing

A nurse reviewer who cannot approve your request is not denying it. They are escalating it, because they are usually not permitted to deny. That means a request stuck after nurse review is waiting for a physician, and the useful intervention is supplying the clinical fact the criteria wanted, not arguing with the nurse.

#What "pended" usually means

Pended is the most common non-decision and it covers several different situations that look identical from outside:

Waiting for clinical documentation that was requested or that never arrived.
Queued for nurse review.
Escalated and queued for physician review.
Waiting on something administrative, such as provider enrollment verification.

These have completely different remedies, and the status alone does not distinguish them. It is worth asking specifically which of these a pended request is in, because "we are waiting on records" and "it is with the medical director" call for opposite actions.

#Delegated review

For some service categories the plan does not review at all. It delegates utilization management to a specialist vendor, commonly for advanced imaging, cardiology, oncology pathways and musculoskeletal services. The request goes to a different organisation with its own criteria, its own portal and its own timelines, and the plan may not be able to tell you much about it. See Delegated utilization management.