Tiêu đề PA Operations Case - 2025.pdf ✅

Prior Authorization Operations Case For this project, please spend 1-2 hours creating a Google doc that outlines your answers to the questions below. If you have any questions, please reach out to us via email. Background on Prior Authorization Prior authorization is a procedure used by health insurance companies to determine if they will cover a prescribed medication. This process is aimed at ensuring the treatment is medically necessary and aligns with the insurer's coverage policies. Unfortunately, this process can be time consuming and confusing to navigate for both patients and their providers. The general process is as follows: 1. A healthcare provider prescribes medication for a patient. 2. If the medication is not automatically covered under the patient's insurance plan, a prior authorization request form must be submitted to the insurance company. The form requires detailed information about the patient's medical condition and why this specific medication is necessary. 3. The insurance company reviews the request to assess the medical necessity of the medication and whether or not it should be covered under the patient's specific policy. This process typically takes a few days, though some reviews are automated and are completed instantly. 4. The insurance company either approves or denies the prior authorization request and responds via fax. a. If approved, the patient’s medication will be covered by their insurance at the pharmacy. b. If denied, the provider must decide if a change in medication is required or if they should “appeal” the insurance company’s decision by writing a letter about the need for coverage. Questions 1. PA example scenario: Assume you are completing a PA for a chronic migraine patient who has been prescribed Emgality for the first time. The patient’s health insurance is United Healthcare. a. Emgality typically requires that patients complete step therapy requirements. Research and list out the step therapy requirements for this medication for the patient’s insurance. Include links to any references you used. b. In filling out the PA, you realize the documentation does not show that the patient has completed all step therapy requirements from the plan. Draft an email to the provider requesting any additional information you think you need to complete a PA for Emgality. c. The patient has never had to go through a PA process before, so they don’t understand why their prescription is not ready yet or what current status is. Draft a text message