How to get a prior authorization submitted and decided

Executive summary. Queue the case, let it go out through the payer transport, and record the decision with its expiry.

Definition

Submission sends the authorization request to the payer; the decision comes back with an authorization number and a date it runs out.

What to do

Open the case and queue it once the clinical information it needs is attached.

The case moves from queued to submitted when it goes out through the payer transport. You do not send it by hand.

When the payer answers, the case records the decision. An approval carries an authorization number and the date it expires.

Note the expiry. A refill after that date needs a new authorization, and the expiry is surfaced before the refill rather than at it.

When the transport is unavailable

If the payer transport cannot be reached, THE CASE STAYS IN THE QUEUE. It is not marked submitted, and it is not lost. That is deliberate: a case recorded as sent when nothing went out is worse than one still visibly waiting, because nobody chases what they believe has already gone.

A denial is not the end. Appeals are their own queue, and the case remains the record of what was asked and what came back.

Frequently asked questions

The case still says queued. Has something gone wrong?

Not necessarily. Queued means it is waiting to go out. If the payer transport is unavailable the case stays queued on purpose rather than claiming to have been sent.