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Julia Ja, OperationsFred Alakbarov, ArchitectureBalash Mirzabey, EngineeringTalk

Insurance eligibility and prior authorization — Coverage checked before the visit, and prior auths prepared for review

This automation checks each patient's insurance before the appointment and flags inactive plans, changed payers or missing details. For services that need prior authorization, it gathers the notes, codes and forms the payer asks for. Staff review and submit, and the request is tracked until a decision comes back.

By Julia Ja, Owner

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Tomorrow's visits · insurance checked

2 to call
  • 8:30 am · plan ended last monthInactive coverage · phone number attachedCall first
  • 9:15 am · new payer on fileMember ID to confirm with the patientCall first
  • 10:00 am · MRI needs approvalRequest pre-filled · nurse to review and submitPrior auth
  • 10:45 am · coverage activeCopay and deductible notedVerified
IllustrationTomorrow's schedule checked overnight, with problems listed for the front desk and nurse.
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Why it matters

The problem it solves

Coverage problems often show up at the front desk, or later as a denied claim. Checking every patient means calls and portal logins, so checks get skipped on busy days.

Prior authorizations take even more work. Staff piece together notes, codes and forms from the chart, then chase the payer for a decision while the patient waits to schedule.

In an AMA survey of 1,000 physicians, practices complete 39 prior authorization requests per physician per week. Physicians and staff spend about 13 hours a week on them.
Source: AMA physician survey (2024)

Example · illustrative

A family medical clinic the night before

  1. 10 pmTomorrow's schedule is checked against each patient's insurance.
  2. One patient's plan ended last monthAnd another has a new payer on file.
  3. At 8 am the front desk sees both flags with phone numbers and calls before the visits.
  4. A third patient needs an MRI that requires approval, and the request is waiting pre-filled for the nurse to review.

How it works

How insurance eligibility and prior authorization works

  1. Starts whenAn appointment is booked or a procedure is scheduled
  2. 1Step 1Check eligibilityAn electronic check with the payer confirms active coverage, copay and deductible before the visit.
  3. 2Step 2Flag problemsInactive coverage, a wrong member ID or an out-of-network plan goes to the front desk with the patient's contact details.
  4. 3Step 3Prepare the prior authIf the service needs approval, diagnosis and procedure codes and the relevant notes are put into the payer's form or portal.
  5. A person decidesReview and submitStaff or the clinician confirm the clinical details and submit the request.
  6. 5Step 5Track the decisionThe request status is checked until the payer answers. Approvals are attached to the visit, and denials go to staff.

Before · by hand

  • Coverage problems surface at check-in or when a claim is denied.
  • Staff call payers or log into portals one by one.
  • Prior auth paperwork is pieced together by hand from the chart.

With insurance eligibility and prior authorization

  • Coverage is checked before the patient arrives.
  • Problems reach the front desk with time to call the patient.
  • Prior auth requests come pre-filled for staff to check and submit.

What we build

The parts of insurance eligibility and prior authorization

Your systems

  • Open Dental
  • Dentrix
  • athenahealth
  • Availity
  • CoverMyMeds
  • Microsoft 365

What we build

  1. 1Schedule feed

    Reads upcoming appointments and scheduled procedures from your practice management or EHR system.

  2. 2Eligibility checks

    Runs electronic coverage checks through a clearinghouse or payer and records plan status, copay and deductible.

  3. 3Front desk flag list

    Shows coverage problems with the patient's contact details, sorted by appointment time.

  4. 4Prior auth packet builder

    Pulls diagnosis and procedure codes and the relevant notes into the payer's form or portal fields for review.

  5. 5Status tracker

    Checks pending requests until a decision comes back, attaches approvals to the visit and sends denials to staff.

Your team decides

  • Clinicians confirm the clinical details before any request is submitted.
  • Staff talk to patients about coverage problems and costs.
  • Appeals of denied requests stay with the practice.

Industries it fits

What insurance eligibility and prior authorization looks like in each industry

Dental practices

Coverage, remaining annual maximum and frequency limits are checked before cleanings, and predeterminations for crowns are prepared. Patients close to their annual maximum are flagged, so the treatment coordinator can discuss costs before the visit.

Everything for dental practices

Your industry isn’t listed, or works differently? Describe it and get an answer in a minute.

Getting started

What you need first

We go through these with you in the audit, before anything is built.

Before we start

5 things to have ready
  • A practice management or EHR system that can share schedule and insurance data.
  • A clearinghouse or payer connection for eligibility checks, or logins for payer portals.
  • A list of services that need prior authorization by payer, or a person who knows them.
  • A signed BAA with each vendor that touches patient data.
  • Staff and a clinician who review requests before they're submitted.

How a rollout runs

  1. 1Map payers and servicesWe list your main payers, how each one confirms coverage, and which of your services need prior authorization.
  2. 2Connect with BAAs in placeWe connect the practice system and eligibility service, with BAAs signed before any patient data moves.
  3. 3Check past schedulesWe run checks on recent appointment days and compare the flags with what the front desk actually found.
  4. 4Start with eligibilityCoverage checks and the flag list go live first, so the front desk gets used to working from them.
  5. 5Add prior auth by payerPrior auth preparation is added one payer at a time, with staff reviewing every request before it's submitted.

What to measure

How to know it's working

Weekly report · insurance eligibility and prior authorization

Illustration

  • Visits with coverage checked ahead

    The basic sign it's running across the whole schedule.

  • Coverage problems found before check-in

    Each one is a conversation moved away from a busy front desk.

  • Claims denied for eligibility

    Shows whether problems are caught before the claim goes out.

  • Prior auths returned for missing information

    Shows whether the packets include what each payer asks for.

  • Visits moved for a pending auth

    Shows where auth tracking and scheduling still need to work together.

We measure the baseline before building, so the change can be compared afterwards.

When it’s not a fit

  • Payer data isn't always current. A plan that shows active can still be wrong, so staff should confirm odd results.
  • Some payers accept only fax or phone, and portals change. Those steps stay partly manual.
  • Prior auth rules vary by payer and change often. Someone at the practice has to own the list of what needs approval.
  • If your practice system can't share schedule or insurance data, setup may need an export or a different connection.

Tool or custom build

Do you need a custom build?

Option A · a ready-made tool

An off-the-shelf tool may be enough

Many practice systems, such as Dentrix and Open Dental, include eligibility checks through a clearinghouse. Availity and CoverMyMeds handle eligibility and some prior auths directly with payers.

Option B · built around your systems

When a custom build is worth it

A custom build makes sense when checks should run on the whole schedule ahead of time, with flags sent your way. It also fits prior auth packets built from your own chart notes.

Not sure which fits?

What it typically costs

Typical ranges as of October 2026. Not a quote.

Ready-made tool, set up by us

An existing platform on your own account, configured for your business.

Setup, one timepaid to Lorryn
$1,500–$3,000
Tool subscriptionpaid to the provider
$100–$300 / month

Fits when your process matches what the platform already does.

Custom build

Built around how you work, with no platform subscription. You own it.

Build, one timebasic version to full version
$2,250–$10,000
Running costshosting and usage, on your accounts
~$5–$25 / month

Fits when your systems, rules or exceptions don't match a ready tool.

Optional Automation Care: $125 · $250 · $375 / month

1, 2 or 3 hours of support a month, with monitoring and alerts included. Without it, you run it yourself after handover.

Typically works with Open Dental, Dentrix, athenahealth, Availity.

Booking into or writing to your field-service, practice or shop software adds up to $500 to the ready-made tool (often a built-in feature) and $500–$1,500 to a custom build.

Your price depends on volume, the systems involved and how many exceptions need a person. Our team confirms a fixed price before any work starts.

Proof and who stays in charge

Who does what

The automation does the routine steps. A person makes the call.

  1. 1Check eligibilityAutomated
  2. 2Flag problemsAutomated
  3. 3Prepare the prior authAutomated
  4. 4Review and submitA person
  5. 5Track the decisionAutomated

Consent and privacy

Patient data is handled only by vendors that sign a Business Associate Agreement (BAA) under HIPAA. Access is limited to the staff and systems that need it.

FAQ

Questions about insurance eligibility and prior authorization

  • Both can share schedule and patient data with outside tools. We check what your version and setup allow.

  • It prepares them. A staff member or clinician reviews and submits, because the clinical details must be right.

  • Those requests are prepared and queued for staff with the form filled in. Electronic submission is used wherever the payer supports it.

  • The front desk gets the flag before the visit. They decide whether to call the patient, update the insurance or reschedule.

  • We use vendors that sign a BAA, limit access to what's needed, and keep records inside your practice systems where possible.

  • Yes. Checks can run overnight for the next day, or further ahead, and results are ready when the front desk opens.

  • Payer data is sometimes out of date. Staff can see the payer's full response, confirm by phone, and correct the record.

Related use cases

Often built together

All automation ideas

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    Book a callJulia Ja, OperationsFred Alakbarov, ArchitectureBalash Mirzabey, Engineering
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