Prior Authorization Review

Welcome to the Prior Authorization Review Guide on the Develop Health platform. This guide provides an overview of the “Submit Prior Authorization” page, detailing its key features and functionalities. Understanding these capabilities can help streamline the prior authorization process, ensuring that patients receive timely care.

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Key Features:

1. Denial Risk Alert:

   • Located at the top of the page, this alert notifies the user about potential risks associated with the current prior authorization. In this case, there’s a high risk of denial due to the patient’s unwillingness to participate in an exercise plan alongside medication.
   • The platform also provides a direct messaging option to contact the patient to address any concerns.

2. Patient Details:

   • Displays essential information about the patient, including:

     • First Name
     • Last Name
     • Address
     • Birthday
     • Phone
     • Member ID

   • An added functionality extracts the Member ID from the insurance card, allowing for accurate data entry.

3. Overview Panel:

   • Offers a snapshot of the patient’s medication information:

     • Name: Jane Smith
     • Medication: Wegovy, 0.25mg auto-injectors
     • Form: Caremark Commercial
     • Payer: Blue Cross Blue Shield, Tennessee

   • The “Previous Prior Auths” section provides a history of the patient’s prior authorizations, indicating the medication, dosage, submission date, and status (e.g., approved or denied).

4. Medical Necessity Questions:

   • This section prompts the user with specific questions to determine the medical necessity of the requested medication. The platform provides evidence-based responses and additional context, ensuring accurate data entry.

5. Evidence and Context:

   • For each question in the Medical Necessity section, the platform offers evidence or context. This aids the reviewer in understanding the rationale behind each response.

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Using the Prior Authorization Review Page:

1. Review Notifications: Start by checking the notification alert to understand any potential risks associated with the prior authorization.

2. Verify Patient Details: Ensure all patient details are accurate. Use the insurance card feature to extract the Member ID, if necessary.

3. Check the Overview: Review the patient’s medication information and previous prior authorizations to understand their medical history better.

4. Answer Medical Necessity Questions: Use the platform’s evidence and context to answer each question accurately.

5. Submit: Once all sections are completed, click on the “Submit” button to finalize the prior authorization.