Prior Authorizations

You can create prior authorization requests for a patient, collect the documentation the payer requires, generate a PDF to send over, and then track the request through to approval or denial.

Prerequisites

Part 1: Create a prior authorization template (EMR)

First, create a prior authorization template for the procedure you are requesting authorization for. The template standardizes the documentation collected on every request for that procedure.

Follow the instructions here to create your prior authorization template.

Steps

Step 1: Create a prior authorization request (EMR)

To create a prior authorization request:

• Go to the EMR (e.g. emr.avonhealth.com)
• Click on the hamburger menu on the top left corner > Patients
• Click on the "View Chart" button of the appropriate patient
• Click the "Bills" shortcut on the top bar and find the "Prior Authorizations" section
• Create a new request and select the prior authorization template for the procedure you are requesting
• Fill out the requisite information:
  • Patient: Confirm that the patient's name, MRN, and date of birth are accurate
  • Insurance: Which of the patient's insurance policies the request is being submitted to. The patient's insurance policies are pulled from the list of policies set on the patient's profile.
  • Procedure codes: The CPT codes you are requesting authorization for
  • Associated diagnoses: The ICD codes that support the request
  • Ordering provider: The provider ordering the procedure
  • Service facility: The location where the procedure will be performed. Follow the instructions here to set up your service facilities.
  • Units requested: How many units of the procedure you are requesting
• Complete the questions from the template with the clinical documentation supporting the request
• All information set is autosaved so click "Finish and Go Back" if you are done with the request for now

Step 2: Add attachments (EMR)

On top of the documentation collected by the template, you can attach additional files to the request — for example chart notes, imaging results, or a payer-specific form.

Step 3: Generate a PDF (EMR)

You can generate a PDF of the request, including its attachments, to send to the payer.

Step 4: Submit the request (EMR)

Click "Submit" to mark the request as submitted. Submitting inside the EMR records that the request has gone out; it does not transmit the request to the payer for you.

Step 5: Add logs (EMR)

You can add logs to a prior authorization request to keep a running record of everything that happens on it.

Step 6: Update the status (EMR)

Once you hear back from the payer, update the status of the request to reflect the outcome:

• Approved: The payer authorized the requested procedure
• Denied: The payer declined the request
• Follow up: The payer needs more information, or you are still waiting on a decision

Step 7: View, edit, and delete prior authorization requests (EMR)

To view, edit, or delete a prior authorization request:

• Go to the EMR (e.g. emr.avonhealth.com)
• Click on the hamburger menu on the top left corner > Patients
• Click on the "View Chart" button of the appropriate patient
• Either:
  • Scroll through the patient's chart to find the desired request OR
  • Click the "Bills" shortcut on the top bar and scroll to the "Prior Authorizations" section to find the desired request
• Click on the prior authorization card to go into viewing mode
• Toggle the top dropdown to go into editing mode
• Scroll to the bottom right-hand corner of the card to find the "Delete" button (NOTE: the "Delete" button is only visible when you are in editing mode)