Medical Assistant Prep / Unit 26 MAS 647 review, 2 to 3 minutes
A Prior Authorization Done Right
The idea
This case is constructed for this course. It follows a medical assistant through a prior authorization, step by step, so that a patient's ordered test is neither delayed nor denied.
In practice
The provider orders an advanced imaging test for a patient whose plan is an HMO. Before calling the imaging center, the medical assistant checks the plan's requirements and finds that this test needs prior authorization. She gathers what the plan's form asks for. That includes the patient's information, the diagnosis codes the provider documented, the test ordered, and the clinical notes supporting the order. She completes every field, because an incomplete form can delay approval. She submits the request through the plan's process and records the date and the reference number in the patient's record. Two days later, she follows up and learns that the plan wants one more note from the record. She sends it the same day. The approval arrives, and she records it with its authorization number and the dates it covers. Then she schedules the test within those dates and tells the patient. Had the plan denied the request, she would have told the provider at once, so the provider could decide whether to appeal or order something else.
Where people slip
Prior authorization is slow when it is incomplete and fast when it is thorough. Checking the requirement first, completing every field, recording reference numbers and following up kept the patient's test on schedule, and kept the patient from receiving a bill the plan would not pay. Recording the approval's dates also protects the next scheduler, who can see at a glance whether the test still falls inside the approved window.
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