📋 Prior Authorization

4 / 518 min

📋Module 5 · Slide 18

Common Denial Reasons — and How to Prevent Them

Denials happen, but most of them are preventable. The top reasons are incomplete clinical information, missing step therapy documentation, and white bagging mandates. We tackle these head-on by educating our MDOs before they even send a referral.

Denial Reasons & Prevention Strategies

Incomplete Clinical Info	Pre-educate MDO staff on documentation checklist; intake team scrubs every packet	Most Common
Missing Step Therapy Docs	Coach providers to document all prior therapy attempts with dates and outcomes	Very Common
White Bagging Mandate	Identify white bagging payors early; pivot to AIC or find alternative solutions	Financial Risk
Wrong Benefit Type	Always verify medical vs. pharmacy benefit before submission	Preventable

When a Denial Happens

If a denial does happen, we prepare the physician with all the clinical guidelines and talking points they need to win a peer-to-peer appeal. Proactive beats reactive every time — but when we do need to appeal, we come prepared.