Loading...
Qualigenix runs prior authorization for independent practices. We confirm eligibility and benefits, check whether each CPT code needs approval with that payer, build the clinical packet, submit it, and follow up until there's an authorization number on file. Your staff gets off payer hold lines, and procedures stop getting rescheduled because an approval never came back.
Outsourcing prior authorization to Qualigenix moves the payer calls, portal logins and fax follow-ups off your front desk. The AMA's 2024 physician survey found practices complete 39 prior authorization requests per physician each week, which takes physicians and staff about 13 hours. Qualigenix verifies benefits 48 to 72 hours before the visit, checks each CPT code against the payer's auth rules, and submits with the documentation that payer's criteria ask for. The approval number is attached to the claim before it goes out. Across all client practices, Qualigenix runs a 4.8% denial rate and a 98.2% first-pass clean claim rate. The work happens inside your EMR (133 platforms supported), and onboarding takes 6 days on average.
Every figure below is measured across the full Qualigenix book of business, not prior authorization alone.
| Metric | Result |
|---|---|
| First-pass clean claim rate, claims accepted on first submission | 0 |
| Denial rate across all claims submitted | 0 |
| EMR/EHR platforms supported, work done inside your system | 0 |
| Specialties, each with assigned specialty coders | 0 |
| Metric | Result |
|---|---|
| Of denials overturned on appeal | 0 |
| Net collections rate | 0 |
| Days in A/R, average before and after Qualigenix | 0 |
| Cash-flow improvement, average across client practices | 0 |
Qualigenix handles each authorization from the scheduled visit to the approval number on the claim. A dedicated team works inside your EMR and payer portals, so nothing gets re-keyed into a separate system.
We confirm active coverage, plan type, network status, deductible, copay and coinsurance through EDI 270/271, the payer portal or a phone call. Checks run 48 to 72 hours before the visit and again on the day of service for surgical cases. Secondary coverage is checked too, so coordination-of-benefits problems show up before the claim does.
Each scheduled service is checked by CPT code against the payer's current authorization list. That covers commercial plans, Medicare Advantage, Medicaid, and the traditional Medicare services added under CMS's WISeR model in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.
We pull the ICD-10 and CPT codes, visit notes, imaging and prior-treatment history that the payer's medical-necessity criteria call for. Gaps go to your clinical team before submission, when they're still easy to fix.
Requests go out by portal, fax or X12 278 transaction, whichever the payer accepts. Each one is tracked against its decision clock: CMS now requires Medicare Advantage, Medicaid and federal marketplace plans to decide within 72 hours for urgent requests and 7 calendar days for standard ones.
When a payer denies a request or asks for a peer-to-peer, we read the specific denial reason the payer has to provide, gather the records that answer it, and schedule the call for your physician. Requests that stay denied are resubmitted or appealed.
The approval number, approved units, CPT codes and date span go into your practice management system and onto the claim. We watch expiry dates and request extensions before a multi-visit authorization runs out.
Qualigenix onboards a practice in 6 days on average and works inside your existing EMR and payer portals, so no scheduled procedure loses its authorization during the switch.
Straight answers on cost, timelines, and how Qualigenix works alongside your staff.
Prior authorization services cover eligibility and benefits verification, checking whether a service needs payer approval, submitting the request with clinical documentation, following up until a decision, and logging the approval number on the claim. Qualigenix also prepares records for peer-to-peer reviews and resubmits or appeals denied requests.