Billing and claims
Prior authorizations
Check whether a service needs authorization, submit a request with the diagnosis, CPT® codes, units, and evaluation report, track approved versus used units per code, and get warned before an authorization runs out.
Prior Authorizations is under Billing (and Prior auth records under Settings for the history).
Does this service need authorization?
Start a New Prior Authorization with the patient, payer, and service type. Sefton checks the payer’s rules and tells you whether authorization is required before you fill anything else in.
Submitting a request
Provider, Diagnosis Code (ICD-10), CPT® Code(s), Units, and dates. Attach an Evaluation Report: select an existing one or Generate Evaluation from Appointment. Submit. The request tracks its status (pending, approved, denied) and the Auth Number when it arrives.
Unit budgets by CPT® code
Each authorization shows Approved, Used, and Remaining units per CPT code. Edit unit budgets sets the approved count per code; used units are tracked automatically from signed notes. The Authorization tracker on the patient record shows units and visits remaining with the expiry date.
Warnings
The Sessions queue and the Billing queues warn when an authorization is close to its unit limit or its end date, so the re-authorization request goes out before care is interrupted. Re-authorization prefills from the current one.
On the claim
Book Appointment carries the Prior Authorization Number; the scrubber blocks a claim whose service exceeds the remaining units.
Frequently asked questions
How are used units counted?
Automatically from signed notes: each billed unit of an authorized CPT® code on a covered date decrements that code's budget.