Prior authorizations have become increasingly important as newer drugs come on the market to treat many diseases and conditions. A proper understanding of the intricacies of the prior authorization process, especially for patients on Medicare, can help streamline the approval process and enhance efficiency in the pharmacy’s prescription fill process. Read on to learn more about prior authorizations and the Pharmacy Technician.
What is a Prior Authorization?
A Prior Authorization (PA) is a process by which after an appropriate request, an insurance company decides if it will pay for a prescription drug under the patient’s prescription drug coverage insurance plan.
When a request for Prior Authorization is submitted, it goes through a step-by-step process of review by the insurance company or its outside contractor in which the request will either be accepted or rejected.
If the request is rejected, an important or even life-saving drug can be denied to the patient.
After a rejection of the Prior Authorization application, an appeal can be filed by the patient’s healthcare provider which can take 30, 60 or even 90 days to complete depending on the insurance company.
Oftentimes, additional information is required by the insurance company to document the patient’s condition and the absolute need for the requested drug.
Usually, a step-by-step approach is taken in which the patient must qualify for the requested medication by first failing a trial of a “first line” medicine which is usually less expensive.
What Types of Prescriptions Require Prior Authorizations?
The following types of prescriptions may require Prior Authorization from the insurance company:
- If a less expensive drug has been tried but has failed and a more expensive medication may be indicated
- If the insurance company has a question that the patient’s diagnosis match the need for the medication
- If the patient and the healthcare provider are adequately aware of the risks associated with the use of the new medication
- If the patient has agreed to comply with the proposed treatment plan which will help improve the chances for the success of treatment
- If the medication is new and relatively expensive and needs to be reviewed on a case-by-case basis
- If the medication is written for a patient who does not fit the usual profile in the insurance company’s database for the particular drug according to the patient’s age and/or gender
- If the quantity or strength of the medication seems unusual for the patient’s age or medical conditions
Qualifications for Prior Authorization Pharmacy Technician Jobs
In order to qualify for a Prior Authorization Pharmacy Technician job, an applicant for this type of position needs to be competent in the following skills and abilities:
- Have an excellent rating on all recent performance appraisals
- Have excellent interpersonal and team skills
- Have excellent working knowledge of excel spreadsheets and be able to analyze and interpret data from them
- Always work in a professional manner
- Have an excellent attendance record
- Be able to stand frequently
- Be able to walk, bend and reach frequently with occasional sitting
- Be able to push and pull and lift materials of up to 40 pounds for distances of up to 10 feet
- Be responsive to auditory alarms and all communication devices such as telephones, beepers, fire alarms, and mechanical failure alarms
- Have sufficient mobility to be able to access equipment and patients
- Be able to withstand minimal to constant loud noises
- Be able to read the information on medication labels
- Be able to utilize repetitive hand motions
- Be able to use protective gear such as gloves and fluid-resistant coats
- Be able to work comfortably with computers, calculators, computer printers, medication carts, and automated dispensing machines
- Have a broad working knowledge of drug names (both trade and generic names)
- Have a good working knowledge of all aspects of mathematics, formulas, and calculations
- Understand Latin and chemical abbreviations
- Be comfortable with aseptic technique
- Understand and be familiar with regulations pertaining to the dispensing of medications
- Understand different storage conditions for pharmaceuticals
- Be able to determine a drug’s formulary status
- Understand computer functions, use of a keyboard and computer functions
- Be able to run fill lists, IVPB lists, and TCE reports
Educational and Licensure Requirements
In order to qualify to work as a Prior Authorization Pharmacy Technician you must possess the following credentials:
- Possess a High School Diploma or its equivalent
- Be registered as a Nationally Certified Pharmacy Technician
Prior Authorization Technician Job Description
The following are some daily job duties performed by a Prior Authorization Pharmacy Technician:
- Review and evaluate the appropriateness and medical necessity of medications based on established criteria
- Understand, anticipate and respond to complex questions from third-party payers
- Facilitate adherence to Medicare requirements including Medicare Local Coverage Determinations (LCD’s) as defined in Section 1869(f)(2)(B) of the Social Security Act to determine if a medication is covered under Part A or B of Medicare. https://www.cms.gov/medicare/coverage/determinationprocess/LCDs.html
- Facilitate adherence to National Coverage Determinations https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
- Facilitate adherence to Advanced Beneficiary Notice (ABN) processes https://www.cms.gov/About-CMS/Agency-Information/Aboutwebsite/Help.html
- Proactively contact third-party parties and initiate communication to ensure appropriate future payment
- Streamline and centralize third party medication prior authorizations of high-cost injectable medications
- Document that ABN has been verified and that ABN has been scanned as a document into the fiscal computer system
- Document that the medication was billed properly according to the ABN
- Prescreen payment sources to identify problematic payers
- Interact with appropriate medical and professional staff on a case-by-case basis to obtain appropriate clinical documentation to ensure accurate indications in the patient’s medical record before completion of third party authorizations
- Maintain current knowledge of medical modalities as well as new protocols established for specific patient populations
- Obtain pertinent medical information to document prior authorization request
- Advise health caregivers and clinic staff about any problematic medications
- Refer appropriate patients to the Medication Assistance Program (MAP)
- Problem solve with HMO and insurance staff
The following are some performance measures to evaluate task performance as a Prior Authorization Pharmacy Technician:
- Demonstrates professional performance displayed by professional behavior, a positive and supportive attitude with customers, co-workers and outside agencies
- Effectively communicates unsupported medical necessity to physicians
- Maintains confidentiality of all patient-related information
- Demonstrates efficiency and effectiveness in chart review functions
- Demonstrates that case-specific documentation is concise and thorough
- Manager confirms that evaluation of the Pharmacy Technician’s knowledge is adequate
- Ensures that customers are polled for feedback on prior authorization services
- Conducts retrospective utilization reviews for denial of payment
- Reviews monthly Medicare write-off information for lack of medical necessity documentation
- Maintain documentation to allow for appropriate follow-up of medication
- Ensure compliance with regulatory and accreditation including HIPPA
- Provide appeal/denial information to physician offices
- Be able to lift up to 10 pounds up to 33% of the time
- Be able to lift up to 20 pounds up to 33% of the time
A career as a Prior Authorization Pharmacy Technician either in a Community or Hospital Pharmacy provides an opportunity for an exciting and essential career in a crucial aspect of pharmacy practice. If a patient has had a trial of a medication that has failed or requires a specialized new medication that is not normally covered by his prescription plan, your assistance in working to obtain a Prior Authorization can make the difference between receiving an essential medication or having to forgo treatment.