Support your healthcare team's administrative workflows with organized prior authorization submissions, referral coordination, clinical documentation and insurance payer follow-up.
Mahaveer Health provides prior authorization and referral management services designed to help healthcare providers understand payer requirements, organize supporting information and track authorization decisions.
Prior authorization is a payer review process that may be required before certain healthcare services, procedures or treatments are provided.
Requests commonly involve relevant patient and provider information, proposed services and documentation supporting applicable coverage or medical necessity criteria.
Referral management focuses on organizing required referrals between healthcare providers, such as a primary care physician and a specialist, and tracking related administrative requirements.
Mahaveer Health's service scope brings these processes together through structured administrative coordination and payer follow-up.
Our services cover six administrative activities involved in determining payer requirements, preparing requests, coordinating documentation and monitoring decisions.
Check whether a planned healthcare service may require prior authorization under the patient's insurance plan.
Coordinate necessary information and prepare administrative submissions for applicable payer authorization requests.
Help organize clinician-provided documentation needed for payer review of the requested healthcare service.
Support required specialist referrals and coordination of referral information between healthcare practices.
Track pending requests, check available payer responses and coordinate outstanding requirements.
Organize administrative follow-up when a payer requests corrections, additional information or a review of an adverse decision.
Both processes may be involved before a patient receives care, but they serve different administrative purposes.
A payer review process that may require approval before a specified service, procedure or treatment is provided.
A provider-directed request or recommendation for another healthcare professional to assess or treat a patient. Some health plans require formal referral documentation.
Organizing request information and follow-up activity helps healthcare teams understand what is needed at each stage.
Review the payer's applicable authorization or referral requirements for the planned service.
Coordinate relevant patient, provider, service and supporting clinical information.
Organize the application and check available required information.
Send the request through the appropriate authorized payer submission channel.
Review payer responses and monitor requests awaiting decisions or information.
Document outcomes and communicate required actions to the responsible healthcare team.
Insurance payers may request relevant medical records to evaluate whether a proposed service meets applicable coverage criteria.
Mahaveer Health's role is to support administrative coordination of clinician-provided documentation, rather than independently make clinical necessity determinations.
Payer responses vary by health plan and service, but these are common administrative situations.
The request has been submitted or acknowledged through the applicable payer process.
The payer is reviewing the request or may require additional information before making a decision.
The payer has authorized the specified service subject to the approval's terms and applicable plan requirements.
The payer has not approved the request. Review may identify applicable reconsideration or appeal options.
Authorization requests often involve several communications between providers, facilities and insurance payers.
Maintaining clear records helps administrative teams track payer responses, required documentation, validity dates and next steps.
Information should be documented and handled according to applicable privacy, access and operational requirements.
Organized prior authorization and referral processes can help healthcare teams identify requirements earlier and coordinate outstanding tasks.
Review possible authorization and referral requirements before planned services.
Help coordinate the documentation and administrative details requested by insurance payers.
Maintain request status information and communicate unresolved requirements.
Support administrative processes for referrals when required by the provider or plan.
Keep request decisions, reference information and next actions organized.
Assist healthcare staff with routine authorization coordination tasks.
Prior authorization works alongside eligibility checks, patient registration and denial management.
Answers to common questions about payer authorization requirements, medical necessity documentation, referrals and request tracking.
Prior authorization is a health plan review process that may require approval before certain services, procedures or treatments are provided or covered.
Prior authorization involves an insurance payer's review of a requested service. A medical referral involves directing a patient to another provider and may have separate plan-specific administrative requirements.
Requirements vary by payer and service. They may include provider orders, relevant medical records, diagnoses, proposed procedures, treatment history and clinical information supporting applicable criteria.
No. Prior authorization does not guarantee that a claim will be paid. Final coverage and payment depend on applicable plan terms, services rendered, claim information and payer adjudication.
The treating clinician supplies the clinical rationale and documentation. The payer applies its applicable coverage and review criteria to decide on the authorization request. Administrative support staff coordinate information but do not replace clinical judgment.
Processing times depend on the health plan, program, service type, request priority, completeness and applicable rules. There is no universal turnaround time for every payer or request.
The requesting team should review the payer's stated reasons and available options. These may include supplying additional information, correcting a request, reconsideration or appeal, depending on the applicable rules.
Healthcare organizations may outsource selected administrative steps, including requirements checks, submission coordination, documentation follow-up and status tracking, with appropriate permissions, oversight and agreed scope.
Connect with Mahaveer Health to discuss payer requirement verification, authorization requests, clinical documentation, referral coordination and status follow-up for your healthcare organization.