> ## Documentation Index
> Fetch the complete documentation index at: https://docs.encoreos.io/llms.txt
> Use this file to discover all available pages before exploring further.

# Prior Authorization — User Guide

> Prior Authorization (PA) lets billers create, submit, and track authorization requests for high-cost behavioral health services (e.g. BHRF admissions, RTC, inp…

## 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.

### 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.

### Who Should Use This Guide

| Role         | Use Case                                                              |
| ------------ | --------------------------------------------------------------------- |
| Biller       | Create, submit, and track PA requests; record reviews and appeals.    |
| Billing lead | Monitor PA status and denials; ensure auth is in place before claims. |

***

## Prerequisites

### Permissions Required

| Permission             | Description                                               |
| ---------------------- | --------------------------------------------------------- |
| `pm.prior_auth.view`   | View prior authorization requests and reviews             |
| `pm.prior_auth.create` | Create new PA requests (drafts)                           |
| `pm.prior_auth.submit` | Submit PA requests to payer                               |
| `pm.prior_auth.appeal` | Record appeals and appeal deadlines                       |
| `pm.prior_auth.edit`   | Edit PA requests and adjust used units (e.g. corrections) |

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

### 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).

***

## Getting Started

### 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.

### 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.

***

## Common Tasks

### 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.

***

### 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 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.

***

### 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.

***

### 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.

***

### 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.

***

## Tips and Best Practices

### 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).

### 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.

***

## Troubleshooting

### 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).

### 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`.

### 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.

### Getting help

1. Check the [PM module README](/index) and related specs for technical details.
2. Contact your organization administrator for permissions and configuration.
3. See [PM-10 spec](https://github.com/Encore-OS/encoreos/blob/development/specs/pm/specs/PM-10-prior-authorization-management.md) for scope and integration with PM-08 and PF-10.

***

## Related Documentation

* **Specification:** [PM-10 Prior Authorization Management](https://github.com/Encore-OS/encoreos/blob/development/specs/pm/specs/PM-10-prior-authorization-management.md)
* **Integration:** [PM-10 Integration](/architecture/integrations/prior-authorization-management-integration)
* **Related:** PM-01 (Patient Registration), PM-02 (Insurance & Eligibility), PM-08 (Claims)

***

**Last Updated:** 2026-02-19