Prior Authorization – Capturing Turnaround Times
India B. Carson, RN, MSN
Clinical Product Specialist
Do you need to capture turnaround times for your prior authorizations? Assuming this is the case, I have a few proposals for you to follow when you are searching for a new software application. These tips can make your life much easier!
Ensure sure your application captures the prior authorization type. Is the request for a concurrent review, a prior to service review, or a retro review? Is the prior to service request for a standard vs. expedited request? These are just a few of the distinct differences that your application will need to address.
Look for a software application that allows for additional time when there is insufficient documentation submitted with the authorization request. In many cases, a request is received but does not have enough documentation to make a decision, necessitating a phone call or an email to the provider asking for more detailed information. Your software should allow for such variances and it should also allow for an extension of time.
Something else you should look for is the ability to enter the turnaround time requirements by company. It is important that you be able to capture a variety of turnaround times by company, because the various companies that you contract with may have different requirements for authorization timeliness.
Additionally, you need a software application that allows you to document the dates and times in the appropriate format. Does your software allow you to document the time you provided written notification to the member recorded down to the time in seconds? Does your regulated entity require this? You will want to investigate this further.
You will also want an application in which you can document the turnaround time requirements in either business days, calendar days, or hours. And, you also want an application in which you can document the notification date and time for the member and the provider.
Examples of what you might need in a software application to document turnaround time by company:
Company XYZ
Rule TypeTurnaround Time- DueExtension TimeConcurrent24 hours48 hoursPrior to Service- Standard15 business days15 business daysPrior to Service- Expedited72 hours48 hoursRetro30 calendar days15 calendar days
These are just some examples of what you may want to capture for your turnaround times. Consult with your regulatory agency’s specific requirements for the appropriate values to capture. Make sure the software you select can accommodate custom fields too, so you can define what values you need for your specific regulatory agency.