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> Prior Authorization Team Lead Checklist
Prior Authorization Team Lead Checklist
Initial Review
Verify that all necessary information is included in the prior authorization request
Determine if the request meets the criteria for approval
Check for any potential conflicts of interest or red flags in the request
Review the patient's medical history and current treatment plan
Assess the urgency of the request and prioritize accordingly
Provider Communication
Contact the healthcare provider to discuss any discrepancies or missing information in the request
Collaborate with the provider to ensure that all necessary documentation is submitted in a timely manner
Communicate the status of the prior authorization request to the provider and address any questions or concerns
Documentation Review
Review all relevant medical records, test results, and other documentation to support the prior authorization request
Verify that the medical necessity criteria are met for the requested treatment or service
Document all findings and decisions in the prior authorization system
Decision Making
Evaluate the request based on clinical guidelines, policy criteria, and medical necessity
Determine whether the prior authorization request should be approved, denied, or modified
Consult with the medical director or other clinical staff as needed for complex cases
Follow-Up
Notify the provider of the decision on the prior authorization request
Provide instructions for next steps, such as scheduling appointments or obtaining the approved treatment
Monitor the status of approved requests to ensure that services are rendered in a timely manner
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