Prior Auth Follow-Up Script

PRIOR AUTHORIZATION STATUS CALL SCRIPT ═══════════════════════════════════════ BEFORE THE CALL ═══════════════════════════════════════ Have ready: - Patient name and date of birth - Member ID and group number - Authorization request reference number ([AUTH_REQUEST_REFERENCE]) - Submission date and method (portal, fax, phone) - CPT code(s) requested and date(s) of service - Ordering provider NPI Open a call log entry. Record the call start time. ═══════════════════════════════════════ OPENING ═══════════════════════════════════════ "Good [morning/afternoon], this is [YOUR_NAME] calling from [PRACTICE_NAME] about a prior authorization status check. Member ID is [MEMBER_ID]. The patient is [PATIENT_FIRST_NAME] [PATIENT_LAST_NAME], date of birth [PATIENT_DOB]. The authorization request reference number is [AUTH_REQUEST_REFERENCE], submitted on [SUBMISSION_DATE] for CPT [CPT_CODE], date of service [DATE_OF_SERVICE]. Before we go further, may I have your name and a reference number for this call?" → Record: representative name, call reference number, date and time. ═══════════════════════════════════════ PRIMARY REQUEST ═══════════════════════════════════════ "Can you confirm the current status of the authorization request, the expected decision date, and whether all submitted documentation has been received?" If the request is in review: "What is the assigned reviewer name or ID, and what is the expected decision date?" If the request is approved: "Please confirm the approved CPT codes, units, date span, and the approved authorization number. I would also like that confirmation in writing or via the payer portal." If the request is denied: "Please state the specific denial reason and the appeal filing deadline. Is a peer-to-peer review available, and what is the scheduling window?" ═══════════════════════════════════════ "WE HAVE NO RECORD" RESPONSE ═══════════════════════════════════════ If the representative says no record exists: "I have a confirmation number [SUBMISSION_CONFIRMATION] from the submission on [SUBMISSION_DATE]. Can you check under the patient name, date of birth, and date of service? If still no match, please escalate to a supervisor and let me know the resubmission requirements before we end this call." → If escalation is needed, request the supervisor name and direct callback number. Do not hang up without a path forward. ═══════════════════════════════════════ RETROACTIVE AUTHORIZATION REQUESTS ═══════════════════════════════════════ If the service has already been rendered and authorization is being requested retroactively: "The service was rendered on [DATE_OF_SERVICE] under [CLINICAL_CIRCUMSTANCE -- emergent, urgent, or unanticipated finding]. Per [PAYER_NAME] policy [POLICY_REFERENCE_IF_KNOWN], retroactive authorization is permitted in this circumstance. Can you confirm the documentation required and the filing deadline for retroactive review?" → Document the policy reference the representative cites. If they cannot cite one, request the policy in writing before proceeding. ═══════════════════════════════════════ WRITTEN CONFIRMATION REQUEST ═══════════════════════════════════════ Before ending the call: "Please send written confirmation of this conversation, including the authorization status, reviewer assignment, expected decision date, and the call reference number, to [PRACTICE_FAX] or via the payer portal under member [MEMBER_ID]." → If written confirmation is refused, document the refusal and the representative's name in the call log. ═══════════════════════════════════════ AFTER THE CALL ═══════════════════════════════════════ In the call log, record: - Call reference number - Representative name - Expected decision date - Action items and follow-up date - Any escalation points Calendar the next follow-up: 48 hours for urgent, 5 business days for routine.