Pharmacist-Led Prior Authorization Support for Medical Practices
Criterion Health Solutions handles insurance approvals, denials, and appeals so your staff can focus on patient care instead of paperwork
Our Services
Prior Authorization Management
We handle the full prior authorization process with insurance providers so your staff never spends time navigating portals, faxing forms, or sitting on hold.
Insurance Appeals & Denial Solutions
When medications or therapies are denied, we prepare and submit professional appeals with clinical justification to secure approvals quickly. Additionally, we offer peer to peer (P2P) preparation and support to ensure the highest likelihood of success.
Benefits Investigation & Verification
We verify patient coverage, medication eligibility, and insurance requirements before submission to prevent delays and rejections.
Medical Records & Document Coordination
We gather, organize, and submit all required chart notes and documentation insurance companies request for approvals and appeals.
Case Tracking and Status Update
Every case is tracked from submission to approval. Your office receives clear status updates without needing to follow up with insurance. We keep full communication with your team throughout the entire process.
Your Dedicated Authorization Department
Criterion operates inside your existing EMR as an extension of your practice. We handle all authorizations and appeals so your staff can focus on patient care.
If your staff can access it, we can work inside of it!
All services are included in every plan.
About Us
About Criterion Health Solutions
Prior authorizations are one of the most time-consuming, clinically frustrating realities in specialty medicine — and they don't belong on your staff's plate.
Criterion Health Solutions was founded by a Doctor of Pharmacy and an operations professional who experienced this burden firsthand. We built Criterion specifically for high-complexity specialty practices — rheumatology, oncology, neurology, dermatology, and endocrinology — where prior authorization volume is high, denials are frequent, and the stakes for patients are real.
What makes Criterion different is the clinical depth behind every case. As a pharmacist-led service, we don't just submit forms — we prepare clinically compelling appeal letters, conduct peer-to-peer reviews directly with payer medical directors, and advocate for your patients at every stage of the process. That's a capability most administrative services simply cannot offer.
Our mission is straightforward: remove the insurance workload from your staff so your team can focus on patient care while we handle the approvals, denials, and appeals.
We operate as a seamless, quiet extension of your office. Your team submits the case. We handle the rest.
How Criterion Works
We integrate into your workflow and manage prior authorizations from start to finish — without adding a single task to your staff's plate.
1. Onboarding & EMR Access (Week 1) We get credentialed in your EMR within the first week — no IT overhaul, no retraining required. Whether you're on Epic, Athena, eClinicalWorks, or another system, we work inside what you already use. Your workflow stays exactly the same.
2. Submission & Documentation Once a case is handed off, we take it from there. We pull the required clinical documentation, complete payer-specific forms, and submit through the appropriate portal or fax channel — fully documented and tracked from day one.
3. Follow-Up, Appeals & Peer-to-Peer Support We monitor every open case and follow up directly with payers on your behalf. If a request is denied, we prepare a clinical appeal immediately. For cases that require it, our pharmacist conducts peer-to-peer calls with the payer's medical director — giving your patients the strongest possible chance at approval.
4. Status Updates & Closure Your team receives clear, timely updates on every case — no chasing, no guessing. Once a decision is reached, we document the outcome and flag any renewals on the horizon so nothing expires unnoticed.
Let’s Work Together
Contact our experts today to schedule a no-obligation consultation and discover how we can elevate your facility’s performance.
