Make the next step visible in every assigned account
Unresolved claims and authorization requests need more than a status label. They need a documented next action, an owner, and follow-through. AuthorizeRx can help organize administrative support around selected billing, prior authorization, and accounts receivable worklists.
The service scope defines what the team can investigate, document, and follow up on. Your organization retains clinical, coding, billing-policy, and financial decisions.
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Two divisions, distinct billing workflows
LTC pharmacy operations and physician practices need different claim inputs, payer processes and review responsibilities. Pharmacy claim and prescription-related work follows the pharmacy’s procedures; physician professional claims follow practice-approved encounter, charge and coding inputs. One workflow is not interchangeable with the other.
The pharmacy billing, prior authorization and AR foundations below remain relevant. The expanded physician modules are proposed for assessment; physician-specific delivery capacity, systems and staffing must be validated.
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Proposed physician revenue-cycle sequence
1. Registration and eligibility
Check demographic and payer information, benefits and coordination-of-benefits questions under practice procedures. Track referral and authorization requirements. Benefits checks and authorizations do not guarantee coverage or payment.
2. Approved charges and coding inputs
Reconcile encounters to the charge queue and enter approved charges. Route missing documentation or coding discrepancies to the clinician or qualified reviewer. Do not infer diagnoses or invent clinical support.
3. Claims and clearinghouse
Check required fields, submit through approved systems when authorized, and track acceptance, rejection corrections and resubmission references for primary or secondary claims.
4. Payment posting and reconciliation
Post approved ERA/EOB and payment information, reconcile remittances, and flag unmatched items, underpayments or credit balances. Financial adjustments and refunds require practice authorization.
5. Denial and appeal tracking
Classify payer denials, identify documentation and deadline requirements, and prepare administrative packets for required review. Record the decision, submission evidence and next follow-up.
6. AR follow-up and reporting
Prioritize aging items, document payer contacts and reference numbers, and keep the next owner and action visible. Report unresolved blockers and decisions needed from the practice.
Keep rejections, denials and receivables in separate queues
Clearinghouse rejections
A rejected claim has not been accepted for processing through that submission path. Identify the reported field or format issue, obtain an approved correction, and track resubmission and acceptance. Resubmission is not a payment outcome.
Payer denials
A payer denial needs its own reason category, response deadline and review route. Identify whether administrative information, qualified coding review, clinical documentation or another practice decision is needed before preparing a correction or appeal.
Unpaid or underpaid receivables
An outstanding balance may be waiting for processing, a payer response, information or a practice decision. Research status and possible payment variances using approved records. Disputes, contract interpretation, patient balances and adjustments go to designated reviewers.
Every queue should record status, last action, owner, next action, deadline or follow-up date, supporting reference and escalation contact. A connected case history preserves the different meanings of these queues.
Proposed denial and appeals module
Use a denial log that separates payer reason, information needed, deadline, reviewer and submission status. Gather permitted records and assemble administrative appeal packets for practice or clinician approval. Track requests and responses without independently writing clinical justifications or signing attestations.
Review recurring reasons with the practice: missing fields, enrollment discrepancies, documentation questions and coding issues may need different corrective owners. A root-cause log supports discussion without claiming every denial is preventable or reversible.
Proposed AR and payment-variance module
Agree aging bands and prioritization rules before assigning work. Document payer status, call or portal references, outstanding requirements and the next permitted action. Separate items waiting on a payer from those waiting on the practice.
Underpayment or contract-variance investigation can compare approved payment and contract information and flag discrepancies for the billing lead. Credit-balance and refund research prepares a review record; it does not authorize refunds, settlements, write-offs, financial-account changes or legal collection activity. Patient-balance questions follow separately approved scripts and escalation.
Proposed patient statements and financial communication
Prepare or coordinate patient statements from practice-approved balance information and templates. Route disputed balances and statement questions to the practice. Patient-responsibility estimates use approved information and may differ from final payer decisions or balances; estimates are not guarantees.
Payment-plan coordination follows practice policy. Support personnel cannot independently change terms, grant concessions or collect funds. Agree the permitted communications, scripts and escalation rules before assigning patient-facing work.
Proposed qualified coding and record reviews
Appropriately qualified personnel may review agreed coding, documentation or billing records, document discrepancies and route corrections to authorized reviewers. Confirm reviewer qualifications and permitted access first. Clinical corrections, coding decisions and compliance judgments remain with the responsible authorized professionals; no certification or audit outcome is promised.
Proposed reporting and shared responsibilities
Reports can show claims awaiting submission, clearinghouse rejections, denial categories, AR aging, follow-up activity and unresolved blockers. Agree metric definitions, approved source systems and reporting cadence. Distinguish an action completed, a claim accepted, a payer decision and a payment received.
The practice supplies approved documentation, charge inputs and policies; identifies qualified coding and clinical reviewers; authorizes access; and retains financial decisions. The proposed support role is to perform specifically agreed administrative steps, record evidence and route exceptions. No collection rate, reimbursement amount or payer outcome is guaranteed.
Billing worklist support
Review assigned claim-status and rejection queues, record payer responses, and identify missing administrative information. Follow approved correction or resubmission steps only within the scope and permissions your team has authorized.
Escalate coding questions, coverage disputes, contract interpretation, and issues that require clinical or management judgment. A completed follow-up action is not the same as a paid claim, and reporting should distinguish the two.
Prior authorization coordination
Track the request from intake through the payer response. Organize administrative requirements, request missing information through approved channels, and maintain follow-up dates.
Clinical justifications, treatment decisions, clinician signatures, and attestations remain with the responsible licensed professionals. Approval and timing are determined by the payer and the specific case; neither is guaranteed.
Accounts receivable follow-up
Work assigned aging categories according to your priorities. Document claim status, outstanding requirements, prior contact, and the next permitted action. Escalate disputes or items that need a billing lead’s decision.
Your organization decides on write-offs, refunds, settlements, payment arrangements, and changes to financial policy. Any patient-facing balance communication requires a separately agreed scope and approved scripts.
One worklist with an actionable history
For each assigned item, define the status, last action, response received, outstanding requirement, next owner, and follow-up date. Agree on which aging items require escalation and how the team should distinguish items waiting on a payer from those waiting on your organization.
This makes review meetings more useful: your team can see what moved, what is still waiting, and which decisions are needed.
Start with a defined category
Rather than handing over an undifferentiated backlog, select a manageable group of work. Examples include pending authorizations, claims awaiting payer status, or a specific aging category. Confirm access and reporting, then review the results before expanding.
Know what remains with your team
Our administrative support is not legal representation, independent clinical appeal writing, debt collection, or authority to change billing or financial policy. Any additional responsibility must be agreed separately and supported by the appropriate qualifications and controls.
Bring us the bottleneck
Describe the worklist, its approximate size, and the points where your staff needs help. Do not include patient records, account details, or claim images in the website inquiry.