Prior Authorization

Health insurers, public agencies like Medicaid, and other health care organizations, utilize prior authorization services to ensure that their beneficiaries receive the most clinically appropriate and cost-effective care, service, or medication. Our pharmacy and clinical teams coordinate a review process that determines whether a course of treatment is necessary, appropriate, and effective, and then approve or deny the request on behalf of Medicaid or other health insurers.

Acute and Ambulatory Care

Our cross-disciplinary clinical team of physicians, nurses, occupational, physical, speech, respiratory therapists and disability specialists can support public programs like Medicaid as well as other health care organizations with medical necessity determinations and appeal related functions. The services include:

  • Designing prior authorization processes and clinical guidelines
  • Reviewing and making clinical determinations on requests through desk or in-person reviews
  • Representing clients at administrative hearings and appeals

We currently review more than 10,000 prior authorization requests a month on behalf of our clients, for services and supports that include:

  • Non-routine medical services and procedures
  • Skilled nursing visits
  • Durable medical equipment
  • Oxygen and respiratory equipment and supplies
  • Home care services, including personal care services
  • Therapy services, including physical, occupational, and speech
  • Orthotics and prosthetics
  • Early intervention

Long-Term Services and Supports

Our clinical team is also experienced in providing prior authorization to Medicaid programs for long-term services and supports (LTSS). Similar to acute and ambulatory care, the team develops processes and guidelines, and reviews and makes determinations on the requests received.

Some of the LTSS requests reviewed include:

  • Skilled nursing visits
  • Durable medical equipment
  • Oxygen and respiratory equipment and supplies
  • Home care services, including personal care services
  • Therapy services, including physical, occupational, and speech

Pharmacy

Our team of pharmacists and pharmacy associates approve or deny requests from providers to prescribe drugs that are on a client’s prior authorization list. To aid in making those decisions, we provide our clients with:

  • New drug reviews
  • Clinical guidelines
  • Decision algorithms
  • Formulary management
  • Drug class or therapeutic class reviews
  • Quality assurance analyses

Our clinical call center exceeds industry standards for call handling performance and provides prior authorization decisions in less than 24 hours of receipt, 365 days a year.