Prior Authorization Certified Specialist (PACS) Program

Who developed PACS: The PACS program was created by a panel of experts with a range of experience from every role involved in the Prior Authorization Process. This allows for you to gain valuable access to inside knowledge and expertise from provider’s offices, pharmacies and Insurance plans. Becoming Certified will allow you to become an expert in your field, distinguish yourself, and become a leader with tremendous career growth potential.

Features include:

• Online, self-paced program designed for busy professionals.
• Contains a glossary, knowledge check points, downloadable resources, applicable case studies and more..
• Have a question? Instant chat function for live support with content related & technical questions.
• Progress check indicators to track your performance

To learn more about each module click on the module below.

1. The Prior Authorization Process

   The student will develop an understanding of the history of insurance, and the development of the prior authorization (PA) process. The authorization process will be divided into the pharmaceutical and service line.

   Learning Objectives:

   Upon completion of this lesson, the student will be able to:

   • Define healthcare authorizations

   • Understand why authorizations exist

   • Gain basic knowledge of each healthcare professional's role in processing a PA request

   • Learn definitions that are pertinent to the authorization process

   • Know the difference between a medication prior authorization and service prior authorization

2. Insurance Policies

   The student will learn important information regarding insurance policies.

   Learning Objectives:

   Upon completion of this lesson, the student will be able to:

   • Gain basic knowledge of the different types of insurance coverage plans

   • Interpret the information that is provided on an insurance card  

   • Understand the Consolidated Omnibus Budget Reconciliation Act (COBRA) and its implications  

   • Evaluate if a policy is in-network or out-of-network

3. Compliance HIPAA, Security, Fraud and Abuse

   Today, providers are using clinical applications such as computerized physician order entry (CPOE) systems, and electronic health records (EHR) for radiology, pharmacy, and laboratory systems. Health plans are providing access to claims and care management, as well as members of self-service applications. While this means that the medical workforce can be more mobile and efficient, the rise in the adoption rate of these technologies increases the risk of security breaches. HIPAA, The Privacy Rule, Security and Fraud and Abuse will be discussed in this lesson.

   Learning Objectives:

   At the end of this module the authorizer will be able to:

   • Gain knowledge of HIPAA and civil/criminal noncompliance penalties

   • Gain knowledge and understanding of the Privacy Rule of Treatment, Payment and Healthcare Operations

   • Understand Security

   • Gain a general knowledge of Fraud and Abuse

4. Medical Records and The Prescription

   Having a basic understanding of what components are in a medical record and prescription can help the authorizer find information efficiently and successfully.

   Objectives:

   • Understand what the purpose of a medical record is how it relates to a PA
   • Understand what information is in a medical record
   • Understand the basics of a prescription
5. Fundamental Information Before the Authorization Process

   The authorizer must understand the value of medical documentation and diagnosis to apply to the Prior Authorization Request. Basics of the ICD 10, CPT codes, Medically accepted indication, and medical necessity will be covered.

   Objectives:

   Upon completion of this lesson, the student will be able to:

   • Understand what a medically accepted indication is
   • Identify the five most common sources of compendia
   • Understand the basics and application of the ICD-10 codes
   • Understand the basics and application of CPT codes
   • Understand the importance of medical necessity
6. Communication Methods of the Prior Authorization

   Communicating Information to the insurance company is a necessary means of the PA process. It is extremely important to understand the different methods of sending and receiving information as well as knowing the most beneficial and effective way of submitting the PA request. These methods apply to both medications and service line.

   Objective:

   • Learn the different methods of sending and receiving information to the Insurance company or authorization company
   • Understand the advantages and disadvantages for each method
   • Learn what documentation and follow up needs to be addressed with each method
7. Service Line, Medication Initiation & Submission of a Prior Authorization

   The steps for processing a Service-line prior Authorization has some similarities to processing a medication prior authorization. In this lesson, we will begin by discussing the steps that are used to submit a service line prior authorization request from the provider’s side. We will then discuss the steps that are involved in submitting a medication prior authorization.

   Objectives

   By the end of this module, the user will begin to have an understanding of the following topics:

   • Understanding the seven steps that are involved in processing and submitting a service-line prior authorization request
   • Understanding the six steps that are involved in processing and submitting a medication prior authorization request
   • Assigning CPT and ICD-10 codes
   • Insurance verification
   • Finding a medically accepted indication or FDA labeled diagnosis for a medication
   • Comparing patient medical records to medical necessity guidelines
8. Outpatient Services

   The outpatient hospital services include many disciplines that require authorization. Some of the outpatient services are radiology, oncology, durable medical equipment and therapies. This lesson will explain each of these service line authorizations and give examples of the process. To understand how to authorize a service, it is important to have a basic understanding of what is involved in specific treatments. The purpose of this lesson is to teach critical thinking during authorization process. Memorizing every service line is not the solution, rather to see common workflows that lead to effective authorization techniques.

   Objectives:

   At the completion of this lesson you will be able to:

   • Begin to understand radiation therapy
   • Authorize radiation therapy.
   • Begin to understand Radiology therapy (Interventional and Diagnostic)
   • Obtain authorization for Radiology Therapy
   • Obtain Authorization for Speech Therapy
   • Obtain Authorization for Occupational Therapy
   • Obtain Authorization for Physical Therapy
   • Obtain Authorization for Chiropractic Service
   • Obtain Authorization for Durable Medical Equipment
9. Out of Network Waivers

   Not all medical services are offered in the specific network. Some network locations can be miles away from the patient. This lesson explores how to request and achieve an out of network waiver.

   Objectives:

   At the end of this module the authorizer will be able to:

   • Submit an out of network waiver request
   • Define out of network benefits
   • Use critical thinking skills to achieve success
   • Build an authorization template
10. Coverage Determination Types in Medication Prior Authorizations

    The term “Prior Authorization” is used universally in the healthcare setting. Prior Authorization can relate to a service procedure, service, device, or medication from a health plan, payer, or insurance company. Although the term “Prior Authorization” is used most often, it is actually a specific type of coverage determination amongst others when referring to medications.  This lesson will discuss the different types of coverage determinations and provide specific, detailed, interactive examples so that the learner will have a thorough understanding of the process.

    The different types of coverage determinations include:

    • Quantity Limits
    • Tier Exceptions
    • Step Therapy
    • Step Therapy Exceptions
    • Non-Formulary Exceptions
    • Prior Authorizations (including High Risk Medications, Part B vs. D, Opioid Overutilization)
    • End-Stage Renal Disease
    • Hospice
    • Drug Utilization Reviews
    • Formulary 

    Learning Objectives

    Upon completion of this lesson, the student will:

    • Learn about the different types of coverage determinations in Prior Authorizations
    • Understand the process of how a prior authorization request gets approved or denied
    • See multiple examples of the complete process of a medication prior authorization request from provider to insurance and patient
    • View different types of communication requests for prior authorization request submission
    • See examples of communication requests to clarify prior authorizations sent from the insurance company
    • See examples of denial and approval letters that have been communicated with the patient and provider’s office
11. Authorization Denials and Appeals

    Not all authorizations are approved. The authorization denials can be addressed and possibly overturned. Strategic methods exist to review the application for authorization and to appeal.

    Objectives:

    At the end of this module the authorizer will be able to:

    • Appeal an authorization denial for both service line and medications
    • Use critical thinking skills to achieve success
    • Understanding how the insurance industry views the authorizations, denials, and appeals will assist the authorizer
    • Appeals, Denials and Redeterminations of Medication Prior Authorizations
12. The Future of Prior Authorizations and Job Opportunities

    The student will understand why the prior authorization field is expected to expand, as well as the need and estimated salaries of the trained professionals in this field.

    Learning Objectives

    Upon completion of this lesson, the student will be able to:

    • Learn why the PA field is expected to grow
    • Understand how each individual in the PA process must play their role well to save time and money
    • Gain basic knowledge regarding different healthcare professionals’ education levels and salaries