Section 01
PA required
A claim came back with PA required. The clock starts here.
- Open a PA case attached to the prescription.
- Capture payer, plan, and required documentation.
- Notify the patient that a PA is being initiated.
PlaybookPrior auths8 min read
Prior auth follow-up playbook for pharmacy teams
Keep prior authorizations moving without losing the thread between payer, prescriber, and patient.
Operational guidance only. Refillops does not make clinical, coverage, or dispensing decisions.
Trust note · Workflow guidance only. Pharmacy teams stay responsible for patient care and clinical review.
Section 02
Prescriber notified
Send a clean, ready-to-action message to the prescriber's office.
- Include patient, drug, dose, payer, and PA reason.
- Attach the reject and any prior context.
- Set an SLA timer for the first response.
Section 03
Waiting office
If the office hasn't responded within your SLA, escalate predictably.
- Polite reminder at 24 hours.
- Phone call at 48 hours.
- Escalate to pharmacist review if there's still no response.
Section 04
Payer pending
Once submitted, treat the payer like any other owner — track status, dates, and contact attempts.
Section 05
Patient update due
Update the patient at each milestone, even if the news is 'still waiting.' Silence drives calls.
"Prior auth submitted today for Adalimumab. Typical payer response is 24–48h. We'll text you with the decision."
Section 06
Follow-up rhythm
Make follow-up a queue, not a memory.
- Daily PA stand-up reviewing aging cases.
- Weekly review of denials and appeals.
- Monthly trend review by payer.
Section 07
Review boundaries
Related
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