Modeled on a prior authorization intake workflow
- Track
- Prior Authorization
- Difficulty
- Medium
- Time
- 16 minutes
Javier Aguirre is 69 and covered under Meridian Advantage HMO. H. Lindqvist, DO ordered pulmonary rehabilitation - 15 sessions over 10/26/2026 to 11/22/2026 - for COPD with acute exacerbation (J44.1). It reached your prior authorization desk on 10/15/2026. The plan pended the request on 10/15/2026 and its notice names three items it still needs: a recent chest imaging report, the pulmonology consult note, and a record of the treatment already tried (inhalers and steroid courses). The office's fax of 10/14/2026 carried only Dr. Lindqvist's history note. The chart shows the chest CT report from 10/02/2026 and the consult note from 10/08/2026 on file; the treatment record has not been found yet. The decision is due 10/22/2026, 7 days from the day the plan logged it in. Your job is to gather and verify what the request needs and route it to the clinical reviewer. The medical-necessity call is theirs to make, not yours.