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Prior Authorization Playbooks (Specialty-Specific)

Six specialty-specific prior auth workflows, payer-by-payer. Code lists, clinical criteria citations, appeal language for common denials, and concurrent review scripts.

6 Playbooks Included

One Playbook Per Specialty

Each playbook is built from millions of authorizations processed across our client base and matches the payer medical policies as of Q1 2026.

Playbook 1

Behavioral Health

Session limits, CPT 90834/90837/90847, carve-out payers, MH parity appeals, IOP/PHP auth requirements.

Playbook 2

Orthopedics

Joint replacement criteria (MCG/InterQual), PT step-therapy documentation, DME pairing, imaging auth flow.

Playbook 3

Pain Management

Injection series limits, RFA/SCS criteria, UDT coverage rules, opioid REMS documentation requirements.

Playbook 4

Cardiology

Stress test / nuclear imaging criteria, device implant auth, specialty pharmacy referrals, CCTA coverage matrix.

Playbook 5

Radiology

High-cost imaging auth workflows (MRI/CT/PET), eviCore and AIM pathways, peer-to-peer scripts, retro-auth limits.

Playbook 6

DME

CMN requirements, CGM/insulin pump documentation, rental vs. purchase decision tree, capped rental rules.

Sample: Behavioral Health Playbook Preview

Session limit thresholds by payer (partial)

  • Aetna commercial: typically 20 outpatient sessions/year before concurrent review
  • UHC (via Optum BH): auth after 6 sessions for CPT 90837 in most markets
  • Cigna Behavioral Health: no auth for 90834, concurrent review at session 12
  • BCBS carve-outs (Magellan, Beacon): payer-specific, check member ID prefix

Parity appeal framework

  • Cite MHPAEA (Mental Health Parity and Addiction Equity Act)
  • Request NQTL (Non-Quantitative Treatment Limitation) comparative analysis
  • Include medical/surgical benefit comparison data
...full playbook covers 9 payers, IOP/PHP authorization workflows, carve-out identification matrix, telehealth parity rules, and a complete denial-to-appeal decision tree.
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Prior Auth Is the Biggest Lever in 2026 RCM

According to MGMA and AMA surveys, 94% of physicians report prior auth causes care delays, and the average practice spends 14 hours per week per physician on authorization work. Yet most denial write-offs from auth failures are entirely preventable, the rules are published, the workflows are predictable, and the documentation requirements are knowable.

These playbooks distill what works across our client base. They aren't theoretical, every auth script, denial rebuttal, and peer-to-peer talking point has been validated against recent payer decisions.

Want us to handle your authorizations? Revenue Synergy's prior auth team processes over 12,000 auths/month with a 96% first-submission approval rate. See our prior auth service.