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What Do Authorization Outcomes Like Auto Approval, Pending, and Review Required Really Mean?

Revolutionizing the world of prior authorizations can sometimes be equated to reading in tongues. Or, in simpler terms, if ever you have received an outcome from an authorization request, say an ‘auto-approval’ or ‘pending’ or even ‘A review is required’, it is likely to say that you no longer know what to do next. These are not just statuses per se; rather they help you identify what needs to be done next in order to keep the patient care processes intact.

In this article we will look into how one can effectively deal with various authorization outcomes and the most important and fun part- how can outsourcing solutions such as Staffingly, Inc. assist in dealing with struggling or challenging situations in a lucrative and logical manner.

Key Takeaways

• Auto Approval: Suggests the patient’s request will be instantly endorsed. No action needed Orderable.
• Pending: The payer needs more time or extra information before making the decision.
• Review Required: Case needs the involvement of a medical expert for evaluation or appraisal from the payer; in most case this requires Putting up documents to support.

The key point is to be able to understand in which way to respond according to the case and this will also decrease the waiting time in patients’ treatment.

Understanding Authorization Outcomes

Each outcome from an insurance portal represents a distinct phase in the prior authorization process. Here’s what they mean and the steps to address them:

1. Auto Approval: No Action Needed

• What It Means:
  An “auto approval” outcome means the insurance company has approved the request without requiring a detailed review. This is often the result of the request meeting all preconfigured criteria.
• What You Should Do:
  • Take note of the transaction id and save any / all approval documents like confirmation letters that you may have.
  • As demonstrated in the transcripts when “GH Stimulation Approval” was saved with a transaction ID and uploaded to ECW (EclinicalWorks), your EMR system’s patient records have these documents attached to them.
  • Notify the care team regarding the approval and continue with scheduling the service for the patient.
• Example from Practice:
  In the case of a Growth Hormone Stimulation Test, the system showed “no action required,” meaning the test could proceed without insurance involvement. The team printed the letter for future reference.

2. Pending: Follow-Up Required

• What It Means:
  A ‘pending’ status means the payer might need more details to review the request wholeheartedly. Such cases are common in incomplete forms and documentation along with documents that need to be processed manually by the payer.
• What You Should Do:
  • Check Documentation: Making sure all the necessary documents such as office visit notes, reports of diagnosis and growth charts etc. have been submitted on the payer portal.
  • Track Progress: Regularly update insurance portals and track pending cases in a spreadsheet or tracker, as shown in transcripts, marking appropriate numbers for authorization.
  • Communicate with the Insurance Provider: If the waiting time exceeds the anticipated time frame, follow up with the insurance company to check in on eligibility.
• Example from Practice:
  Each time there was an office visit that was marked as “pending” the team ought to look for the pending authorization number and record it in the tracker. They checked for updates on this information in a timely manner so as not to unintentionally overlook it.

3. Review Required: Prepare for Manual Submission

• What It Means:
  The insurance payer requests a medical review. This is common in complicated few cases or the ones who require expensive treatment. For a payer to make a decision, more clinical data like medical history or diagnostic checks are to be provided.
• What You Should Do:
  • Gather Necessary Documentation: Include the patient’s recent office visit notes, diagnostic lab reports, and any images like X-rays or MRIs.
  • Submit Quickly: The payer portal should be utilized to upload all necessary documents, including lab reports and growth charts, for Growth Hormone Stimulation Test requests.
  • Track the Timeline: Review cases often have specific deadlines for submission or resolution. Ensure timely submission to avoid delays.
• Example from Practice:
  In terms of Dexcom G7 supplies for a patient, the team noted that a “review required” outcome required the uploading of progress notes and previous prescription records. These were also uploaded at the right time in order to get the approval.

Best Practices for Handling Authorization Outcomes

1. Maintain Accurate Records: Always document authorization numbers, transaction IDs, and any status changes in the patient’s chart for future reference.
2. Streamline Communication: Use secure messaging systems like Clara or ECW to update patients and internal teams on status changes.
3. Leverage Outsourcing: Partnering with experts like Staffingly, Inc. can reduce the administrative burden of prior authorizations by ensuring compliance with payer requirements and tracking outcomes effectively.

What Did We Learn?

Healthcare teams can improve patient experience by understanding details like automatic approvals and required outcome authorizations, reducing waiting times, and being proactive through documentation and follow-ups.

Healthcare experts can outsource their processes to lose engaging with such complex administrative tasks by working with outsourcing specialists such as Staffingly, Inc.

FAQs

Q1: What is a transaction ID, and why is it important?
A transaction ID is a unique identifier provided by the payer to track an authorization request. It is essential for referencing the case in future communications with the payer.

Q2: How long does a “pending” status last?
The timeline varies by payer, but most cases are resolved within 7–14 business days. Regular follow-ups can help expedite the process.

Q3: What should I do if my case remains in “review required” for an extended period?
Call the payer and inquire about the reason for the delay. Be prepared to submit any additional documentation they request.

Disclaimer

The information in our posts is meant to inform and educate both healthcare providers and readers seeking a better understanding of healthcare processes. However, it is not a substitute for professional advice. Insurance requirements, policies, and approval processes can vary widely and change over time. For accurate guidance, healthcare providers should consult directly with insurers or use professional resources, while patients should reach out to their insurance providers or healthcare professionals for advice specific to their situation.

This content does not establish any patient-caregiver or client-service relationship. Staffingly, Inc. assumes no liability for actions taken based on information provided in these posts.

For tailored support and professional services,

please contact Staffingly, Inc. at (800) 489-5877

Email : support@staffingly.com.

About the Author : Monica Michael is a seasoned Prior Authorization Specialist with years of experience in streamlining insurance processes for healthcare providers. She is passionate about simplifying complex administrative tasks to help hospitals focus on delivering exceptional patient care.