Prior Authorization and Eligibility: high-yield desk drill

The rule

A thin packet is a gather step. Submit or route a complete packet. This desk does not approve or deny.

Next step

If a named finding is missing, request that finding. If the portal is down, use the backup channel and timestamp it.

Never miss

• Not every service is gated.
• Covered and authorized are different.
• CMS publishes expedited and standard clocks for impacted payers. Confirm the current rule.
• Proprietary criteria products are named only as concepts.

Traps

• Approving to keep turnaround pretty.
• Copying another patient's imaging.
• Promising claim payment from an authorization.

Shortcuts

• Member, provider, service, then clinicals.
• Expedited is a definition.
• Note: reviewed, missing, next owner.

Terms

• Gated. Authorization is required for payment.
• Complete request. The plan's required elements are present.
• Refer. Send coverage doubt to the designated clinician.

Memory hooks

• GATHER-OR-REFER. Never invent, never refuse coverage from this desk Thin chart rule.