General PA
This person initiates the prior authorization.
Who is the provider?
This is the status when medication will not be covered by the insurance.
What is denied?
This is the other name for Medical Group.
What is TPA/Third Party Administrator?
Type of approval may need to be provided by a payor before acquiring a medication or treatment.
What is a prior authorization?
This pushback is required if the agent provides a PA that is Future dated, Expired, Denied or Pending.
What is "Is there an active one?"
This is what we input when the agent says Pre-D is required.
What is Mark "No" to PA and Mark "Highly Recommended" to Pre-D.
If an agent offers to start the prior authorization process, this is the only appropriate response.
What is "By the way, I am not initiating a prior auth; just inquiring about the submission process or status, if applicable"?
This is the status when PA is approved for the provider with a different diagnosis code.
What is, "Approved for different diagnosis".
This PB is used when the agent provides the PA turn around time exceeding 30 days.
What is, “Can you check that, please? I usually get a different answer in similar cases.”
When asking how to obtain prior authorization, these are the four pieces of information we need to attempt to collect.
What is the department name, phone number, website and fax number?
The PA is cancelled and there is no active PA on file. This is the proper way to enter that data on the platform.
What is "Not on file?"
This PB is used if the agent does not specify business days or calendar days for PA turn around time.
What is, "Is that business or calendar days".
This pushback is required when we are told that a PA is required and member's plan is a secondary plan.
What is "Is that true when the plan we're calling on is secondary?
This is a formal review of a member’s requested medical care compared to their insurance’s medical and reimbursement policies. (Not an approval or denial)
What is Predetermination?
This is the TN used if the agent does not provide us with the Prior Auth approval number.
What is" Representative could not provide authorization approval number."