Prior Authorization Basic Training Program (PABT)

Module 1 lays the foundation for understanding the prior authorization landscape. This module goes over what prior authorization is, how it came to be, and who is involved in this utilization management process.

Module 2 covers insurance policies, payments, and copay assistance. Processing prior authorization requires knowledge of federal, state, and commercial health insurance, drug tiering, formularies, and determining insurance eligibility. To help understand patients who cannot afford prescriptions, there are patient assistance programs and copay programs designed to help patients gain access to necessary medications.

Module 3 mitigates risk surrounding compliance standards in the industry by reinforcing law and ethical practice. For reimbursement, it is expected that authorization professionals protect patient information to the standard of HIPAA and ensure accurate coding.

Module 4 explains in detail the components of the medical record and prescription to aid in the authorization process. Valuable information is conveyed in these documents and can help the authorization find information efficiently and successfully.

Module 5 focuses in the value of medical documentation and coding to apply to the prior authorization request. Understanding the ICD-10, CPT, and HCPCS codes as well as medically accepted indications and medical necessity will support the authorization process.

Module 6 provides in-depth explanations of the communication methods for the prior authorization process. Effective communication with the payer is imperative for submitting a prior authorization and receiving updated status for the patient.

Module 7 takes a step-wise approach to the submissions of prior authorization for both medical benefits and prescription benefits. This approach is from the provider perspective to ensure all steps are appropriately taken and the risk of denial is minimized.

Module 8 covers the broad scope of specialties and clinical practice which require authorization. Some services require additional attention, including diagnostic and interventional radiology, oncology, specialty medication, infusion services, J code medications, durable medical equipment, and various therapies. The function is not to memorize the special cases, but to critically think through the workflows.

Module 9 provides guidance on how to request and achieve an out of network waiver for special cases. This is particularly important for patients who experience limited accessibility and mobility or require particular specialists.

Module 10 discusses the frequent coverage determinations for medication claims that require additional considerations. This includes quantity limits, tier exceptions, step therapy, step therapy exceptions, and non-formulary exceptions. Considerations are also made for high-risk medications, opioids, Medicare Part B vs Part D, End Stage Renal Disease, hospice, and Drug Utilization Reviews.

Module 11 describes the denial process and how to overturn the decision with an appeal. Strategic methods exist to review the application for authorization and to appeal with success.

Module 12 presents the future of prior authorizations on a macro level and opportunities in the field as an individual. Prior authorizations continue to expand as the healthcare industry adapts to new challenges.