Prior Authorization: Streamlining the Member and Provider Experiences

At Luminare Health, we work every day to understand pain points in both member and provider experiences, and to find meaningful ways to improve them. One area where we consistently succeed is the Prior Authorization (PA) process. 

Prior authorization is a crucial step in determining medical necessity for coverage. When done well, it ensures members receive the care they need quickly and efficiently. Ideally, it also reduces unnecessary strain on provider resources. We are committed to making healthcare more efficient and accessible for everyone involved. Streamlining the PA process is a major part of that mission.  

Exceeding Expectations in Prior Authorization 

The Centers for Medicare & Medicaid Services (CMS) requires 72 hours for urgent PA turnaround for certain payors, while the American Medical Association (AMA) supports 24 hours for urgent care and 48 hours for nonurgent care. 

Our Utilization Management (UM) department routinely beats both benchmarks. For Non-urgent PA turnaround, the new CMS requirement for Certain Payors is seven (7) calendar days. Our team average is approximately half of that. For urgent requests, our average turnaround time is even quicker: about half a day. 

These results are not coincidental. They reflect the hard work, expertise, and commitment to service excellence of our team. 

What Sets Our Approach Apart 

Our success lies in a strategic, member-first approach. We ensure PA is a value-add for employer sponsored plans without becoming a burden for members or physicians.  

Key elements of our model:  

• A targeted and limited scope of services requiring PA, reducing unnecessary steps 

• Streamlined systems that minimize friction 

• A dedicated Utilization Management (UM) team made up of trained and experienced medical professionals 

This combination results in faster approvals, fewer provider headaches, and better outcomes for members. 

Why Speed Matters in Prior Authorization 

For our members, expedited PAs mean quicker access to necessary treatments, reducing anxiety and preventing potential health deterioration. For providers, swift decisions reduce the administrative burden and free up provider resources and allow for quicker scheduling of care for members. 

Delays in the PA process can possibly lead to postponed treatments, increased emergency room visits, and overall dissatisfaction among all stakeholders. Timely authorizations make a measurable difference – and we take pride in delivering just that.  

Better PA, Better Healthcare 

Efficient Utilization Management benefits the entire healthcare ecosystem. When we reduce unnecessary delays, we help: 

• Improve Health Outcomes through timely, evidence-based care 

• Strengthen Provider Relationships by fostering trust and collaboration

Looking Ahead 

As the process for prior authorization evolves for the industry, we will continue to refine our processes so that we stay ahead of the curve. By leveraging technology, data analytics, and a mission-driven team, we set new standards in healthcare management every day. Want to learn more about how our UM team is making a difference? Fill out the contact form below.