Prior authorization

Three checks that stop a denial after surgery

Where surgery and imaging auths go wrong, and how we run each check for you.

Why it has to happen before the date of service. About 85% of payers allow no retro authorization, and the rest give you a few days. Once the case is done without a valid auth, the denial cannot be billed to the patient.

The work below is done by an AI we built. It signs into the same payer and UM portals your team uses, like a new employee would, and does this work itself. No integration project, no API build.

Check 1

Is an auth actually required?

The eligibility screen says no auth required.
↓
The case is scheduled. Nothing is saved.
↓
After surgery the claim denies for that exact auth (CARC 197).
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Denied after surgeryNo retro auth, and the patient cannot be billed.
How we solve itThe AI checks the plan's own current policy for that code and place of service before every case, not just the eligibility screen. When one is needed, it builds and submits the request itself, straight from the chart, and saves the answer with the case.
The return
Every case, before the date
the answer is saved with the case, so nobody has to remember it on the day.
Check 2

Is it with the right review company?

The request goes to the payer on the card.
↓
But a utilization management company, EviCore, Carelon, TurningPoint or Magellan, actually reviews that service.
↓
It sits in the wrong queue until the surgery date arrives.
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Surgery moves, or goes ahead unapprovedEither way, nobody ever reviewed it.
How we solve itThe AI works out which utilization management company reviews that service for that plan and files the request there directly, in whichever portal that is. It tracks the request to a determination, and flags your team if they need more.
The return
3x the working hours
the queue is worked 24 hours a day instead of one shift.
Check 3

Does the approval match the case?

The auth is approved and sitting on file.
↓
The case bills different codes, dates, units or site.
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Denied anyway. An approval is not a guarantee of payment.
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Denied after surgeryOr rework, weeks later, if someone catches it.
How we solve itBefore the claim goes out, the AI reads the approval letter for the exact codes, dates and units that were approved, and checks the claim against it. Mismatches get fixed before the payer ever sees them.
The return
Minutes, not weeks
fixed before submission, not fought after a denial.
8 to 12
auths a person gets through in a day when the mix is surgery-heavy; imaging-only queues run closer to 20
60%
of prior auths are still handled manually
24 hours a day
the queue is worked, every day, with status checked daily instead of when someone has time

What this looks like in practice

$1.4M

One Florida cardiology service line was writing off $1.4 million a year to prior auth, across just three payers and one physician. That is where we started with them: our AI running auth for those three payers, extending into eligibility and denials next.

Where your team stands

Three numbers of yours. Rough is fine; the math only uses what you enter.

Surgery, imaging, injections, DME
Full-time equivalents
CARC 197, last six months, divided by six
Auths per person per day today8 to 12 is typical when the mix is surgery-heavy
20
Person-days a year on authsat 12 a day, surgery-heavy mix
4,167
Denials that never happenif a third of your no-auth denials are prevented
600 a year
Cases that go ahead approved, that did not before
600 a year
A+ from KLAS, June 2026Becker's 2026 Top RCM CompaniesHeadspace · SonderMind · Ideal Eye SurgeryRothman Orthopaedic Institute · Columbia Orthopaedic GroupNo code list. No payer network to join.

Worth twenty minutes?

Bring your last six months of CARC 197 denials and we will show you which of the three checks is failing most often, and what running it takes. If your workflow is already tight, we will say so.

Reply with a day that works and we will set it up.

Retro authorization availability, UM vendor routing, the approval-does-not-guarantee-payment rule, round-the-clock operation, and per-person daily throughput (8 to 12 on surgery-heavy queues, closer to 20 on imaging-only) are from Magical's RCM workflow reference and the field experience of Magical's orthopedic sales team. The share of authorizations still handled manually is the 2024 CAQH Index. CARC 197 is the X12 code for authorization absent. The cardiology figure is the write-off exposure at a current Magical engagement, unnamed at the customer's discretion; it is the size of the problem we were brought in on, not a result to date. KLAS A+ likelihood to recommend, June 2026. Headspace, SonderMind and Ideal Eye Surgery are published case studies; Rothman Orthopaedic Institute and Columbia Orthopaedic Group are current Magical customers. The calculator assumes 250 working days and 12 auths per person per day for a surgery-heavy mix; the "third prevented" line is an illustration, not a guarantee, and the calculator uses only the numbers you enter.