21 Day Cadence
A brand- New referral enters the queue. What stage of the process begins?
Initiation
Which queue contains referral that are usually zero to two days old?
Initiations
The payer has approved the medication. Which status should be documented?
Approval or Determination Favorable.
What must be documented after every provider, patient, or payer interaction?
The date, contact method, person contacted, outcome, next step, and follow-up date.
Who is typically the associate first point of support for a process question?
The Lead
When should the first follow-up occur after the initiation period?
Day 3, according to the 21-day cadence.
Which queue generally includes active follow-up referrals between Day 7 and 13?
Follow- Ups
The payer has the request but has not issued a decision. What status applies?
Pending Review
The provider says chart notes will be sent to plan tomorrow. What should the associate document?
Provider stated chart notes will be sent to plan tomorrow. Document the next follow up
A patient is upset but there is no immediate safety or access concern. What should the associate do first?
Listen, gather complete information, attempt to resolve within role, and involve lead / supervisor as appropriate.
How often should standard follow-ups occur before Day 15?
Every 2 business days
Which queue should be worked oldest referral first?
Reauthorization, beginning with the most aging or urgent expiration date
The payer states the medication does not meet coverage criteria. What is the status?
Denial
What is a call tracking?
Note hub for all documentation related to the patient profile.
What is the normal escalation path?
Associate, to Lead to Supervisor
At what point does a referral move into the Final attempt phase?
Beginning on day 15
Which queue includes referral that are 15 days or older?
Final Attempts
The same PA was submitted twice. What should the associate identify?
Duplicate PA
What is the PA Comment Section?
Where all related information to the PA is located.
What should the associate tell the caller when a supervisor not immediately available?
Leadership will return the call promptly, while the associate gathers all relevant information and routes the escalation via email
What normally occurs on Day 21 when there has been no response and no active payer review?
Complete the final documentation and remove the referral according to the process.
The PA expires in 30 days. Which work type should be started?
Reauthorization
The authorization period has ended and no renewal is active. What status applies?
Expired PA
What should never happen when the associate cannot reach a supervisor during an escalation?
The issue should never be left unresolved or undocumented. The associate must collect all details, reassure the caller, and route the escalation.
A patient may miss medication because of an unresolved urgent PA issue. What should happen?
Escalate immediately, document the urgency, gather all relevant details, and route to leadership for prompt action.