Prior Authorization — User Guide

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Module: Practice Management (PM)
Feature: Prior Authorization Management
Version: 1.0.0
Last Updated: 2026-02-19

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Overview

Prior Authorization (PA) lets billers create, submit, and track authorization requests for high-cost behavioral health services (e.g. BHRF admissions, RTC, inpatient). You can record status (draft → submitted → pending → approved/denied/appealed/expired), add concurrent reviews, and manage denials and appeals. Auth is verified at claim scrub (PM-08) so claims align with authorized units.

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Key Capabilities

• Create and save PA requests (patient, payer, service type, CPT, diagnosis, justification, urgency) as draft.
• Submit PA requests and track status; capture determination date and denial reason.
• Record concurrent or retrospective reviews and link them to the authorization.
• Track appeal deadlines and used vs. authorized units.
• See AHCCCS rules (e.g. BHRF 5-day urgent) applied or flagged where configured.

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Who Should Use This Guide

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Prerequisites

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Permissions Required

Contact your organization administrator if you don’t have the required permissions.

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Before You Begin

• Patient and payer must exist (PM-01, PM-02).
• Service type, CPT, and diagnosis codes should be available (e.g. from PF-70 or org config).

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Getting Started

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Accessing Prior Authorization

1. Go to Practice Management in the main menu.
2. Open Prior Authorizations (or the PA entry from the patient record).
3. Use the list to filter by patient, status, or date range.

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Understanding the PA List

• Status: Draft, Submitted, Pending, Approved, Denied, Appealed, Expired, Cancelled.
• Urgency: Routine, Urgent, Emergent (affects AHCCCS rules such as BHRF 5-day urgent).
• Units: Requested, approved, and used units appear on the PA detail.

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Common Tasks

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Create a PA request (draft)

When to use: You need to request authorization for a patient and service before billing. Steps:

1. Click New prior authorization (or open from the patient’s PA tab).
2. Fill in required fields:
   • Patient — select from your organization’s patients
   • Payer — select from active payers
   • Service type — e.g. BHRF, RTC, inpatient (from configured list)
   • CPT code(s) and Diagnosis code(s) — as required by payer
   • Clinical justification — brief justification for the request
   • Urgency — Routine, Urgent, or Emergent
   • Requested dates and units — start/end and number of units
3. Optionally set requesting/servicing provider, facility.
4. Click Save draft.

Result: The PA is saved with status Draft. You can edit and submit it when ready.

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Submit a PA request

When to use: The draft is complete and ready to send to the payer (manual/portal or, when available, FHIR PA API). Steps:

1. Open the PA request from the list or patient record.
2. Confirm all required fields and justification.
3. Click Submit.
4. If your organization uses a payer portal or file-based process, follow that process and then record the submission in Encore Health OS (status Submitted).

Result: Status becomes Submitted (then Pending while the payer reviews). Determination date and denial reason can be entered when the payer responds.

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Track status and enter determination

When to use: You received an approval, denial, or need to update status. Steps:

1. Open the PA from the list.
2. Update Status (e.g. Approved, Denied).
3. Enter Determination date and, if denied, Denial reason.
4. For approved PAs, enter Approved start/end dates and Approved units if different from requested.
5. If the payer gave an Auth number, enter it.
6. Click Save.

Result: Status and dates are stored; used units can be updated by claim scrub (PM-08) or manually when needed.

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Record a concurrent review

When to use: The payer requires a concurrent review (e.g. during a stay). Steps:

1. Open the approved PA.
2. Click Add review (or Concurrent review).
3. Choose Review type (Initial, Concurrent, or Retrospective).
4. Enter Review date, Reviewer (name or ID), Clinical notes, and Determination (Approved, Denied, Pended, Modified).
5. Optionally set Next review date.
6. Save.

Result: The review is linked to the authorization and appears in the PA’s review history.

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Appeal a denial

When to use: A PA was denied and you are filing an appeal. Steps:

1. Open the denied PA.
2. Enter or confirm Denial reason.
3. Enter Appeal deadline (if applicable).
4. Click Mark as appealed (or set status to Appealed).
5. Complete the appeal via the payer’s process; when the payer responds, update status and determination as needed.

Result: Appeal deadline is tracked; status Appealed keeps the request visible for follow-up.

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Tips and Best Practices

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Do’s

• Create the PA request as soon as the service is planned so approval is in place before claims.
• Enter determination and denial reason as soon as the payer responds.
• Use Urgent or Emergent when AHCCCS rules (e.g. BHRF 5-day) apply so the system can flag or apply exemptions.
• Adjust Used units only when correcting data; normal updates come from claim scrub (PM-08).

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Don’ts

• Don’t submit a PA without required fields and justification; payers may reject or delay.
• Don’t forget to set the appeal deadline when appealing a denial.

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Troubleshooting

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I don’t see Prior Authorizations in the menu

Cause: Your role may not have PA permissions.
Solution: Ask your administrator to assign pm.prior_auth.view (and create/submit/appeal/edit as needed).

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I can’t submit a PA

Cause: Required fields may be missing or you may lack submit permission.
Solution: Check that patient, payer, service type, CPT, diagnosis, justification, and requested dates/units are filled. Ensure you have pm.prior_auth.submit.

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Used units don’t match what we billed

Cause: Claim scrub (PM-08) updates used units when claims are linked; manual corrections may be needed.
Solution: If you have pm.prior_auth.edit, open the PA and adjust Used units as appropriate. Ensure claims are correctly linked to the authorization in PM-08.

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Getting help

1. Check the PM module README and related specs for technical details.
2. Contact your organization administrator for permissions and configuration.
3. See PM-10 spec for scope and integration with PM-08 and PF-10.

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Related Documentation

• Specification: PM-10 Prior Authorization Management
• Integration: PM-10 Integration
• Related: PM-01 (Patient Registration), PM-02 (Insurance & Eligibility), PM-08 (Claims)

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Last Updated: 2026-02-19