Prior Authorization

If the insurance carrier requires a prior authorization, the case management team will assist in securing the authorization accurately and in a timely manner. This procedure is part of our organization's core competency. The case managers serve as payer policy experts and will coordinate the prior authorization process, assisting the provider in assembling the appropriate medical documentation according to payer requirements. Whether the provider or the case manager submits the prior authorization, the case manager follows the activity through to completion to record the outcome and provide updates to all stakeholders.

As part of our standard operating procedures ("SOPs"), our team contacts the patient's insurance carrier, if applicable, to verify existing coverage limitations and benefits. Detailed benefits will be clearly categorized for the physician to include:

• Annual deductible (individual vs. family)
• Annual out-of-pocket maximum
• Pharmacy benefit cap
• Prescription drug deductible
• Tiered reimbursement rates (e.g. some payer criteria include Tier 1 = 80% reimbursed,
  Tier 2 = 70% reimbursed, Tier 3 = 50% reimbursed, etc.)
• Maximum cost-share based on days' supply
• Prior Authorization / step edit requirements