# Authorization exception matrix

Worked example companion. Fictional scenario; no measured results.

Give every pending request a reason, an owner and a next action before adding another status poll.

## How to use this sheet

Replace the example rules with your own. Keep each acceptance decision linked to its owner and evidence. Use the blank CSV to record your actual process; the example CSV contains teaching material.

| Queue state | Next action | Responsible role |
| --- | --- | --- |
| Missing documentation | Request the named item and retain a due date | Administrative coordinator |
| Clinical ambiguity | Review the clinical record in its approved system | Qualified clinical reviewer |
| Submission outcome unknown | Check acknowledgment before retrying | Submission owner |
| Payer response overdue | Follow the agreed escalation procedure | Authorization lead |
| Decision received | Verify scope and validity before communication | Authorized staff |

## Workflow

1. **Register request** (Administrative team): Minimum necessary identifiers and an owner.
2. **Check packet** (Staff + checklist): Apply current payer-specific completeness rules.
3. **Submit and record** (Supported interface): Retain the acknowledgment or unknown state.
4. **Follow up** (Assigned staff): Route missing items, pending responses or decisions.

Exception: Missing documents return to their owner. Clinical questions go to qualified reviewers. Unknown submission outcomes require acknowledgment checks before another attempt.

## Measurement

Separate staff handling minutes from elapsed payer response time. Count requests by payer and service, disclose exclusions, and report the baseline and pilot dates. Faster internal handling alone does not establish faster authorization.

## Limitations

- No real patient data or healthcare engagement evidence was used.
- Payer support, organizational approval and qualified review are prerequisites for implementation.
- This is administrative workflow design, not medical guidance, payer approval or a compliance assessment.

Source page: https://www.opsautomators.com/work/healthcare-prior-auth-automation
Prepared September 7, 2026.