Resources for Rheumatology Practices
Practical checklists, intake templates, payer guidance, and staff-facing FAQs to streamline prior authorizations, verifications, and appeals for biologics, infusions, and advanced therapies.
Clinical & Submission Guidance
Biologics & Targeted DMARDs
What to include: concise one-page clinical summary, prior DMARD trials with dates, relevant labs (CRP/ESR), and objective disease activity indicators.
Infusion Authorizations
Key items: signed infusion order, site-of-care verification, facility NPI, dosing rationale, and consent/infusion schedule when available.
Imaging and MSK Procedures
Best practice: document conservative therapy attempts, specific clinical indications, and attach recent imaging reports or findings summary.
Practice Administration
Intake & Verification
Standardize fields: demographics, insurance identifiers (BIN/PCN), ordering provider NPI, diagnosis codes, medication history, and most recent labs/imaging dates.
Submission & Tracking
Use payer portals first; attach a one-page summary as the first document. Track submissions by internal Case ID mapped to payer submission ID and expected decision window.
Payer Guidance & Variability
Medicare Advantage, Medicaid MCOs, and commercial plans all differ in PA rules. Always check the payer portal for required forms, step therapy, and preferred submission method before sending.
Common denial triggers
Missing prior therapy documentation; lack of objective data; site-of-care restrictions for infusions; incorrect benefit pathway (medical vs pharmacy).
Tips to reduce rework
Attach a concise clinical summary first, include dates and reasons for prior therapy stops, and name the treating physician in attestation statements for appeals.
Quick FAQs
- How quickly do you verify benefits?
- We aim to complete eligibility checks same day when requested; plan-specific clarifications may take longer.
- What documentation reduces denials?
- A signed order, one-page clinical summary, prior therapy timeline with dates/reasons, recent labs/imaging, and explicit monitoring/consent notes for infusions.
- Do you handle appeals and peer-to-peer reviews?
- Yes. We prepare clinical appeal packets, request peer-to-peer reviews when available, and manage escalations to external review if needed.