Executive summary. Prior authorization is a payer review that may be required before a medication or service is covered.
Definition
Prior authorization is a utilization-management process in which a payer reviews a requested medication or service before coverage is confirmed.
Where this work lives in Attergo
Authorization coordinators work from the Attergo Authorizations Dashboard, Cases Queue, Case Workspace, Appeals Queue, Expiring Approvals, and SLA Board. Open or create the case, capture the payer decision and the supporting information, assign the next action, and update the case as it moves.
A request usually needs patient, prescriber, diagnosis, treatment, and supporting information, and the exact requirements differ by payer and by medication. Most delays trace back to a missing or mismatched item rather than to a lack of effort.
Review and follow up
Tell the patient what is happening, who owns the next step, and when to expect an update. Use the prescriber and payer channels the request requires, and record decisions and deadlines where the next person will find them.
Final decisions stay with the role your organization holds accountable for them. Record the decision on the item, with the evidence behind it, so the next person to open it does not start over.
Frequently asked questions
Who should use this Attergo workspace?
The role that owns the next action leads it: a billing specialist, an authorization coordinator, an inventory lead, a pharmacist, a compliance lead, or a finance reviewer. Access follows the role your organization assigns.
Referenced standards and further reading
- CMS: Interoperability and prior authorization ↗Centers for Medicare & Medicaid Services
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