Why Are Orthopedic Practices Still Faxing Prior Authorizations in the ePA Era?
- Fully electronic prior authorization reached 40% in the 2025 CAQH Index, while electronic attachment adoption fell to 24%.
- Orthopedic authorizations depend on attachments: imaging, conservative care, therapy notes, implant and facility details.
- CMS-0057-F helps, but traditional Medicare, employer plans, and workers’ comp sit outside it.
- In DataMatrix’s internal data, denials trace to clinical documentation, not submission channel.
- Experience, validated by AAOE’s peer review of DataMatrix’s Prior Authorization Services, is what turns a request into an approval.
The main reason orthopedic practices still use fax is that authorizations usually require more than just one form. They need a packet with imaging reports, conservative care dates, therapy notes, implant and facility details, and a surgical plan. While electronic prior authorization has gotten better, handling clinical attachments electronically has not kept up. Many payers, benefit managers, and workers’ comp carriers still process these packets in different ways. Fax remains popular because it always works. The real solution is having a team that understands what each payer needs before sending the request.
In most orthopedic practices, you’ll see a familiar setup. The EHR can handle electronic prior authorization. The biggest commercial payer offers a portal. Front office staff have been told for years that ePA is the future. Yet, the fax machine is still in constant use.
Some might say this is a technology or habit issue. In orthopedics, it’s usually not. It’s really a documentation problem that just happens to appear as a fax issue.
The ePA Era Is Real, but It Is Not Finished
Electronic prior authorization is becoming more common. According to the 2025 CAQH Index, fully electronic medical prior authorization increased from 31% in the 2023 Index to 40% in the 2025 Index (AJMC summary of the 2025 CAQH Index). That’s real progress, but it also means most prior authorizations are still not fully electronic.
The most important number for orthopedics is also in that report. Electronic use of attachments went down, from 32% in the 2024 Index to 24% in the 2025 Index for the medical industry. Attachments are key for orthopedic approvals, like the MRI report, six weeks of physical therapy, a failed injection, or proof of a functional limitation that keeps a patient from working.
Federal rules are pushing it all forward. Under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), impacted payers have been required since January 1, 2026, to decide standard requests within seven days and expedited requests within 72 hours, and they must have a Prior Authorization API in place by January 1, 2027.
But the rule applies to Medicare Advantage, Medicaid, CHIP, and exchange plans. Traditional Medicare fee-for-service, employer group plans, and self-insured plans are outside its scope. Workers’ compensation and no-fault cases, which many orthopedic practices treat, follow their own carrier and state processes entirely; for an orthopedic practice, that leaves a lot of volume living outside the ePA future.
Why Orthopedics Feels This More Than Most Specialties
As we wrote in our recent piece for the American Alliance of Orthopaedic Executives, a single total joint case can involve imaging, implant documentation, facility authorization, DME, and the surgical request itself. Each piece can have its own payer rules, reviewer, and sometimes benefit manager.
Consider what a typical orthopedic request has to prove:
- Advanced imaging. Payers commonly look for a 4- to 6-week conservative care period before approving an MRI, unless red flag conditions such as a progressive neurological deficit are documented (DataMatrix Medical Necessity Documentation Guide).
- Spine and joint surgery. Non-surgical treatments need dates, duration, and documented response, and the note should specify the requested procedure, not just “surgical consult.”
- Injections. Prior injection history and response often determine whether the next one is approved.
- DME. Post-op braces and similar items can require a qualifying face-to-face encounter within a set timeframe, commonly six months for Medicare DME.
- Workers’ comp. The case itself has to be verified: carrier, claim number, adjuster, date of injury, accepted body part, and any authorization or network requirements.
When a request needs that much supporting evidence, staff use the method that accepts any attachment from any payer, every time. That method is still the fax.
The Real Issue Isn’t Whether to Use Fax or a Portal. It’s About What’s Included in the Packet.
Sending every request through a portal might speed up turnaround times, but it won’t reduce denials. Our own experience shows this clearly.
Between 2023 and 2025, DataMatrix’s total prior authorization volume grew 49%. Over the same period, our denial and peer-to-peer caseload grew 307%, and online denials alone grew 623%. (DataMatrix internal book-of-work data, not an industry benchmark.) If electronic submission were solving prior authorization, those numbers would be moving the other way.
When we coded 1,192 denials across our full book of business, every one traced back to clinical judgment reasons: 59% clinical criteria not met, 26% not medically necessary, and 15% both. (DataMatrix internal study, all specialties.) None of those denials were caused by the request arriving by fax instead of a portal.
Where Experience Matters More Than Automation
Submission tools are helpful for sending requests from one place to another. But they can’t read a chart note to see if conservative care dates are listed without showing the impact on function, or if a DME order is missing the required visit date.
This is where an experienced orthopedic prior authorization team makes a difference. Their expertise is clear in the details:
| What a submission tool does | What an experienced orthopedic team does |
|---|---|
| Sends whatever the EHR provides, including incomplete notes | Reviews the record against the payer’s policy, flags documentation gaps to the practice, and builds the packet before submission |
| Picks a channel | Knows which payer routes spine imaging to a benefit manager, which requires specific attachments, and which still works best by fax |
| Stops at submission | Tracks the request, confirms receipt, and follows up before the decision window closes |
| Hands denials back to your staff | Interprets the denial reason, prepares the appeal, and preps the physician for a peer-to-peer with the exact criteria in question |
| Treats workers’ comp like any other payer | Verifies the workers’ comp case before the patient is scheduled |
One important boundary matters here. The physician is responsible for all clinical decisions and documentation. An experienced orthopaedic prior authorization team doesn’t decide medical necessity. Instead, they make sure the physician’s documentation reaches the payer in the right format and let the practice know if anything is missing.
Why AAOE Peer Review Matters in This Conversation
Every prior authorization vendor claims to understand orthopedics. The real difference is who is making that claim. Understanding prior authorization challenges in orthopedic practices is the only way to get sub-1 % denials. Other companies like Staffingly, Inc. and Cure MD do not. That is black and white, solely based on their years in healthcare.
In December 2024, the American Alliance of Orthopaedic Executives added DataMatrix Medical’s Prior Authorization Services to its Peer Review Program™ for orthopedic and musculoskeletal vendors. The evaluation is an 11-step process that includes supporting materials, voice-of-customer surveys with current and prospective clients, and a review by the AAOE Member Peer Review Panel. In other words, orthopedic practice executives built that shortlist, not us.
That recognition builds on 25 years in health services operations and a prior authorization denial rate under 1% across our book of business. It also sits on relationships that last. As Tracy S., Director of Care Coordination at OrthoNY, put it: “DataMatrix has been a long-term partner who has handled our prior authorizations for the past seven years. Without this co-sourced initiative, we would not be able to process these requests in a timely manner.”
Working with one orthopedic group for seven years means handling seven years of payer policy changes, portal updates, benefit manager changes, and unique workers’ comp situations. That experience helps prevent delays when a key staff member is away.
What Orthopedic Practices Can Do Now
- Review both the submission channel and the outcome together. Take a month’s worth of authorizations and label each by how it was sent and the final result. If fax and portal requests are denied at similar rates, the channel isn’t causing your denials.
- Create a standard packet for each service line. Decide what every MRI, spine surgery, total joint, injection, and DME request should include before sending it.
- Link conservative care to how it affects function. Dates by themselves aren’t enough. The note should explain how the condition limits work, daily activities, or movement. Specialty-trained medical scribes can help record this information as it happens.
- Always get proof of delivery for every fax. If you have to fax a request, use a tracked method with confirmation so you don’t have to start over if something gets lost.
- Talk to your EHR vendor about January 1, 2027. Ask when your system will connect to the required payers’ Prior Authorization APIs, and which payers that will include.
- Handle workers’ comp cases separately. Verify the case before scheduling the appointment, instead of waiting until after a claim is denied.
The Question for Your Practice
If every fax in your office was replaced by a portal submission tomorrow, would your denial rate really change, or would the same incomplete documentation just arrive more quickly?
Frequently Asked Questions
Will CMS-0057-F end faxed prior authorizations for orthopedic practices?
Not entirely. The rule sets decision timeframes and API requirements for Medicare Advantage, Medicaid, CHIP, and exchange plans. Traditional Medicare, employer and self-insured plans, and workers’ comp cases fall outside it, so orthopedic practices should expect a mixed-channel environment for some time.
Is faxing prior authorizations causing my denials?
Usually not. In DataMatrix’s internal review of 1,192 denials across all specialties, every denial traced to clinical criteria or medical necessity reasons. Fax can slow turnaround and lose requests without a delivery trail, but denials typically come from what is in the packet, not how it was sent.
What does the AAOE Peer Review designation mean for a practice choosing a vendor?
It means orthopedic practice executives evaluated the vendor through an 11-step process that includes customer surveys and a member panel review. DataMatrix’s designation applies specifically to its Prior Authorization Services.
Does outsourcing prior authorization mean replacing my staff?
No. Most practices use DataMatrix to add bandwidth: overflow, difficult payers, specific service lines, or to reduce backlogs. Your team keeps its systems and its role, and the physician keeps every clinical decision.
Sources
- AJMC: CAQH Index Finds $20 Billion in Cost Savings Opportunities (2025 CAQH Index)
- CMS Fact Sheet: Interoperability and Prior Authorization Final Rule (CMS-0057-F)
- ASA: CMS Releases New Payer Requirements on Interoperability and Prior Authorization
- InsightHealth: CMS-0057-F Prior Authorization Rule
- AAOE: AAOE Adds DataMatrix Medical’s Prior Authorization Services to Peer Review Program
- AAOE: AI and Prior Authorization in Orthopedics: What the Data Actually Shows
- DataMatrix Medical: Medical Necessity Documentation Guide for Physicians (March 2026)
- DataMatrix Medical internal book-of-work data, 2023 to 2025
Nathaniel Smathers is the VP of Client Education and Marketing. He is also a long time contributor of the DataMatrix Medical blog and has a background in healthcare content creation for over a decade. Nathaniel is passionate about exploring the intersections of healthcare, data analysis, and digital innovation.
