Prior Authorization Checklist

PRIOR AUTHORIZATION CHECKLIST ═══════════════════════════════════════ SECTION 1: BEFORE YOU START ═══════════════════════════════════════ 1.1 VERIFY COVERAGE [ ] Confirm patient insurance is active for the date of service [ ] Verify the specific plan type (HMO, PPO, POS, Medicare Advantage) [ ] Identify the correct payer department for authorization requests [ ] Note the payer's PA submission method (portal, fax, phone) 1.2 CHECK PA REQUIREMENTS [ ] Look up the CPT/HCPCS code(s) in the payer's PA-required list [ ] Confirm whether the place of service changes the PA requirement [ ] Check if the referral source affects authorization rules [ ] Verify if the diagnosis code triggers automatic PA requirements [ ] Note any payer-specific clinical criteria (InterQual, MCG, eviCore) 1.3 GATHER CLINICAL DOCUMENTATION [ ] Obtain relevant clinical notes from the ordering provider [ ] Collect diagnostic test results supporting medical necessity [ ] Gather prior treatment history documenting step therapy (if applicable) [ ] Obtain the letter of medical necessity from the treating provider [ ] Confirm ICD-10 codes match the clinical documentation ═══════════════════════════════════════ SECTION 2: SUBMISSION ═══════════════════════════════════════ 2.1 COMPLETE THE PA FORM [ ] Fill in patient demographics and insurance information [ ] Enter correct CPT/HCPCS codes with modifiers [ ] Include ICD-10 diagnosis codes (primary and secondary) [ ] Specify requested units, frequency, and duration [ ] Enter ordering and rendering provider NPI numbers [ ] Include the expected date of service or service start date 2.2 ATTACH SUPPORTING DOCUMENTATION [ ] Attach clinical notes [ ] Attach diagnostic results [ ] Attach letter of medical necessity [ ] Attach prior authorization from referring provider (if applicable) [ ] Attach step therapy documentation (if required by payer) 2.3 SUBMIT AND DOCUMENT [ ] Submit via the payer's required method [ ] Record the submission date and time [ ] Save the confirmation number or fax transmission receipt [ ] Note the payer's stated turnaround time [ ] Calendar the follow-up date (48 hours for urgent, 5 business days for routine) ═══════════════════════════════════════ SECTION 3: FOLLOW-UP ═══════════════════════════════════════ 3.1 48-HOUR CHECK (URGENT) / 5-DAY CHECK (ROUTINE) [ ] Call the payer PA department using the confirmation number [ ] Verify the request is in review (not stuck in intake) [ ] Confirm all documents were received [ ] Note the reviewer name or ID and expected decision date 3.2 ESCALATION PATH [ ] If no decision by the payer's stated turnaround: call and request supervisor review [ ] If partial approval: document what was approved vs. requested [ ] If peer-to-peer review is offered: schedule within 24 hours [ ] Document every contact (date, time, representative name, reference number) 3.3 DENIAL RESPONSE WINDOW [ ] If denied: note the specific denial reason and appeal deadline [ ] Request the denial in writing if not received within 48 hours [ ] Route to appeal workflow using the appropriate appeal letter template [ ] Calendar the appeal filing deadline with a 5-day buffer