Benefit and eligibility verification
Confirm active coverage, plan type, network status, deductible position and whether the service requires authorization at all.
Approved before the visit
Prior authorization handled before the patient arrives, not after the denial.
Most authorization losses are avoidable. T Zync verifies benefits, submits complete requests, tracks approval windows and flags reauthorization dates so services are not rendered against an expired or missing approval.
Designed for
Practices delivering infusions, imaging, procedures and high-cost drugs
No PHI through public forms
01 What this solves
The denial that costs the most is the one nobody checked for.
Prior authorization failures are expensive because the money is usually unrecoverable. A biologic infused without an active approval, an imaging study performed on an expired authorization, or a procedure billed under the wrong CPT code than the one approved will generally be denied with no appeal path, and the practice absorbs the drug cost.
T Zync treats authorization as a pre-service control, not an administrative errand. Every request is checked against the payer's medical policy before submission, matched to the exact codes that will be billed, and tracked from submission through approval, expiry and renewal.
The work covers commercial plans, Medicare Advantage, Medicaid managed care and state Medicaid programs, with payer-specific portals and documentation formats maintained per plan.
02 What is included
Authorization managed end to end.
Medical policy review
Check the payer's published criteria before submission so the request matches the clinical documentation that exists.
Code-accurate submission
Submit against the exact CPT, HCPCS and diagnosis codes that will appear on the claim, including units and site of service.
Clinical documentation assembly
Collect chart notes, prior therapy history, lab values and imaging results required by the plan's criteria.
Peer-to-peer coordination
Schedule and prepare peer-to-peer reviews when an initial determination is adverse, with the criteria in hand.
Status tracking and escalation
Follow pending requests through payer portals and phone queues with defined escalation timing.
Reauthorization calendar
Track approval expiry, remaining visits or units, and renewal deadlines before they lapse.
Denial root-cause feedback
Route authorization denials back into scheduling and documentation so the same gap does not repeat.
03 Rules that govern this work
The deadlines and rules we work against.
Authorization is governed by published payer and state rules. These are the ones that most often decide whether a claim is payable.
| Rule | What it means in practice |
|---|---|
| Texas gold carding (HB 3459) | State-regulated plans must exempt a physician from prior authorization for a service when the physician's approval rate for that service meets the statutory threshold over an evaluation period. Exemption status is worth tracking; it removes authorization work entirely for qualifying services. |
| Texas prompt pay | Clean claims under state-regulated HMO and PPO plans carry statutory payment deadlines, which makes a clean first submission financially significant. |
| Medicare Advantage coverage criteria | MA plans must follow Traditional Medicare coverage rules for basic benefits. An MA denial that conflicts with a National or Local Coverage Determination is appealable on that basis. |
| Approval is code-specific | An approval issued for one CPT code does not cover a different code billed on the claim. Code changes after approval require a new or amended request. |
| Retroactive authorization | Most commercial plans allow retroactive requests only for urgent or emergent care within a short window. Elective services rendered without approval are usually written off. |
Rules change by plan year and by state. T Zync verifies current payer policy at the time of each request rather than relying on prior precedent.
04 How it runs
A pre-service control with named ownership.
- 01
Intake
Receive the order, confirm coverage and determine whether authorization is required for the exact service and site.
- 02
Prepare
Match documentation to published criteria and assemble the submission package.
- 03
Submit and pursue
File through the payer's required channel and work the request to a determination.
- 04
Protect
Record approval numbers, units and expiry, and calendar the reauthorization before it lapses.
FAQ Prior authorization guidance
Prior authorization questions, answered clearly.
For guidance specific to your specialty, payer mix and systems, speak with T Zync.
How long does prior authorization take?
It depends on the plan and the service. Standard commercial determinations are commonly issued within a few business days, while expedited requests carry shorter regulatory timelines and complex drug reviews can take longer. T Zync tracks each request against the plan's published determination window and escalates when it is exceeded.
What happens if a service is performed without authorization?
The claim is usually denied with the financial responsibility falling on the practice rather than the patient, and appeal rights are limited. This is why T Zync treats authorization as a pre-service gate rather than a billing task.
Do you handle peer-to-peer reviews?
T Zync schedules the peer-to-peer, confirms the reviewer window and prepares the clinical points against the plan's own criteria so the physician's time is spent on the decision, not on retrieval.
What is gold carding, and does it apply to my practice?
Texas law requires state-regulated plans to exempt physicians from prior authorization for a service when their approval rate for that service is consistently high. It applies to state-regulated plans, not to self-funded ERISA plans or Traditional Medicare. T Zync tracks exemption notices so exempt services are not resubmitted unnecessarily.
Do you track reauthorizations?
Yes. Approval expiry dates, remaining units and remaining visits are calendared, and renewal requests are started before the current approval lapses.
Can you work inside our EHR and payer portals?
Yes. T Zync works within the practice's existing systems and payer portals under practice-issued credentials with role-based access.
05 Keep exploring
Related revenue-cycle services.
Before the claim
Provider Credentialing
CAQH, PECOS and payer enrollment through to activation and revalidation.
After the denial
Denial Management
Root-cause appeals and prevention rules that stop repeat leakage.
Specialty depth
Rheumatology Billing in Texas
Infusion authorization, biologic J-codes and buy-and-bill protection.
Start with clarity