Chapter 24: Prior Authorizations

Overview

Prior Authorizations (PAs) are insurance approvals required before providing home health services to patients. The Prior Authorization Center helps you request, track, and manage these authorizations efficiently, ensuring visits are covered by insurance and preventing claim denials.

This chapter covers the complete PA lifecycle: automatic creation from OASIS assessments, insurance approval tracking, visit generation, and automatic status management based on usage and expiration dates.

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Understanding Prior Authorizations

What is a Prior Authorization?

A Prior Authorization is:

• Pre-approval from an insurance payer to provide a specific number of visits for a patient
• Required by most private insurance companies and some Medicaid plans before services begin
• Not required for Medicare (Medicare uses a different authorization system through OASIS assessments)
• Time-bound with a specific effective period (start date → end date)
• Discipline-specific (separate approvals for RN, PT, OT, HHA, etc.)

Example: Your patient has Blue Cross insurance. Before you can start PT visits, Blue Cross requires you to call them and get pre-authorization. They approve 10 PT visits valid from Apr 1 - June 30, 2026. This approval is recorded as a Prior Authorization in the system.

Why Prior Authorizations Matter

Reason	Impact
Claim Payment	Without a valid PA, insurance will deny claims and you won't get paid
Visit Planning	PAs define how many visits are approved, helping you schedule appropriately
Compliance	Exceeding approved units without renewal can result in audits or contract termination
Patient Communication	Ensures patients know their insurance coverage status before services begin

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How Prior Authorizations Are Created

Prior Authorizations are automatically generated when an OASIS assessment (SOC, ROC, or Recertification) is approved in the QA Center. The system reads the treatment frequency from the OASIS Plan of Care and creates a PA with requested units.

Automatic Creation Process

Step 1: OASIS Assessment Approved

• Clinician completes an OASIS (SOC, ROC, or Recert)
• QA reviews and approves the OASIS
• OASIS status changes to Approved

Step 2: System Reads Treatment Frequency The approved OASIS includes the Plan of Care with treatment frequency for each discipline:

• Skilled Nursing: 2x/week for 2 weeks, then 1x/week for 6 weeks = 10 visits
• Physical Therapy: 3x/week for 4 weeks = 12 visits
• Occupational Therapy: 2x/week for 3 weeks = 6 visits
• Home Health Aide: 3x/week for 8 weeks = 24 visits

Step 3: Prior Authorization Created The system automatically creates a Prior Authorization record with:

• Patient - Linked to the patient from the OASIS
• Care Order - Linked to the care order
• Payer - Automatically linked to the patient's primary insurance payer
• Source Document - The OASIS assessment that triggered the PA
• Effective Dates - From the care order's certification period (e.g., Apr 1 - June 29, 2026)
• Status - Pending (needs insurance approval)
• Line Items - One line per discipline with requested units:
  • Skilled Nursing (SN): Requested = 10, Approved = 0
  • Physical Therapy (PT): Requested = 12, Approved = 0
  • Occupational Therapy (OT): Requested = 6, Approved = 0
  • Home Health Aide (HHA): Requested = 24, Approved = 0

What If There's No Primary Payer?

• If the patient has no primary payer configured (self-pay or pre-CCN agencies), the PA is still created but with payerId: NULL
• These "non-billable PAs" can be approved without an authorization number
• Useful for tracking visits internally even if insurance billing doesn't apply

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Prior Authorization Statuses

Prior Authorizations move through several statuses during their lifecycle:

Status Definitions

Status	Color	Meaning	Can Edit?	Can Generate Visits?
Pending	Orange	Awaiting insurance review. You've submitted the request but haven't received approval yet.	Yes	No
In Progress	Blue	Insurance is actively reviewing your request.	Yes	No
Approved	Green	Insurance has approved all requested units. Visits can be generated.	Yes	Yes
Partial	Yellow	Insurance approved some, but not all, requested units. Visits can be generated for approved disciplines.	Yes	Yes
Denied	Red	Insurance denied the entire request. Services cannot be provided without appeal or new PA.	No	No
Expired	Gray	The effective end date has passed. No longer valid for new visits.	No	No
Exhausted	Purple	All approved units have been used. No remaining visits available.	Yes (can extend units)	No
Revoked	Red	Insurance revoked a previously approved PA (rare, usually due to eligibility loss).	No	No

Auto-Managed Statuses

Two statuses are automatically updated by a daily cron job (runs at 1:00 AM every day):

1. Expired Status

• Trigger: Today's date > PA end date
• Auto-Update: Any PA with status Approved or Partial automatically becomes Expired when the end date passes
• Example: PA effective Apr 1 - June 30, 2026. On July 1, 2026, it automatically changes to Expired

2. Exhausted Status

• Trigger: For each discipline line, usedUnits >= approvedUnits (all approved units have been used)
• Auto-Update:
  • If all discipline lines are exhausted and PA is Approved → becomes Exhausted
  • If PA is Exhausted and you increase approved units (extend the authorization) → automatically reverts to Approved
• Example: PT line has 10 approved units. After 10 PT visits are completed, usedUnits = 10, so the PT line is exhausted. If PT is the only discipline, the entire PA becomes Exhausted.

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Navigating the Prior Authorization Center

Dashboard Statistics

At the top of the PA Center, six statistics cards provide a quick overview:

Card	Description	Calculation
Total PAs	Total number of PAs in the system	Count of all PA records
Pending Approval	PAs awaiting insurance decision	Status = Pending or In Progress
Approved	PAs currently active and usable	Status = Approved
Expired/Exhausted	PAs that are no longer valid	Status = Expired or Exhausted
Denied/Revoked	PAs that were not approved or were cancelled	Status = Denied or Revoked
Total Units	Total approved visit units across all PAs	Sum of all approvedUnits from all lines, showing used vs remaining (e.g., "748 Used / 486 left")

Search and Filters

Search Bar:

• Search by patient name, authorization number (auth #), or payer name
• Updates results in real-time as you type

Filter Dropdowns:

1. Status Filter - Show PAs by status (All, Pending, Approved, Expired, etc.)
2. Patient Filter - Show PAs for a specific patient (useful for multi-episode patients)

Prior Authorization Table

The main table displays all PAs with the following columns:

Column	Description
Patient	Patient name (blue text = clickable link to patient profile)
Payer	Primary insurance payer name. Shows "No primary payer" if patient has no payer configured (non-billable PA).
Auth #	Authorization number provided by insurance. Shows "Not assigned" if insurance hasn't approved yet or if it's a non-billable PA.
Effective Dates	Start date → End date (e.g., "Apr 02, 2026 - Jun 01, 2026")
Units	Summary of approved units usage. Format: X / Y Used where X = units used, Y = units approved. Second line shows remaining units (e.g., "3 / 3 Used, Exhausted" or "0 / 0 Used, 11 remaining").
Status	Color-coded status badge (see status table above)
Actions	Two icon buttons: Eye icon (view details) and Pencil icon (edit/update)

Row Colors and Indicators

• No special highlighting - Standard PA in normal status
• Red "X" units text (e.g., "3 / 3 Used, Exhausted") - All units have been used
• Status badge colors - Instant visual identification of PA state

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Viewing Prior Authorization Details

Click the eye icon in the Actions column or click the patient name to open the PA Details page.

Summary Cards (Top Section)

Four summary cards provide at-a-glance information:

Card	Data Shown	Description
Status	Current PA status badge	Color-coded status (e.g., Green "Approved", Purple "Exhausted")
Total Approved Units	Total number of visits approved across all disciplines	Example: "3" means 3 total visits approved (could be 1 SN + 2 HHA, etc.)
Units Used	Total number of visits completed so far	Example: "3" means all 3 approved visits have been completed
Units Remaining	How many visits are left to use	Formula: Approved - Used. Example: "0" means fully exhausted.

Authorization Information Section

Field	Description
Authorization Number	The insurance-provided authorization number. Shows "Not assigned" if pending approval or if it's a non-billable PA.
Effective Period	Date range the authorization is valid (e.g., "Apr 02, 2026 - Jun 01, 2026")
Authorized By	Name of the agency staff member who recorded the approval (e.g., "Michael Rodriguez") and the date (e.g., "Apr 08, 2026")

Patient Information Section

• Name - Patient's full name
• Date of Birth - Patient's DOB (e.g., "Jan 01, 1950")

Payer Information Section

Shows the primary insurance payer name and type:

• Example: "Blue Cross Blue Shield" - Type: "Private Insurance"
• If no payer: "No primary payer. Assign primary insurance on this patient and recertify to link a payer for billing."

Service Lines Table

This is the most important section, showing the breakdown by discipline:

Column	Description
Discipline	Type of service (Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, Medical Social Worker, Home Health Aide)
Requested	Number of visits requested from insurance (pulled from OASIS Plan of Care)
Approved	Number of visits insurance approved (manually entered after insurance call)
Used	Number of visits completed so far (automatically tracked as visits are completed)
Remaining	Visits left to use (Formula: Approved - Used)
Progress	Visual progress bar showing usage percentage. Color-coded: - Red bar at 100% = All units used - Green/Blue bar = Units still available
Generation Status	Shows if visits have been generated from this PA. Text: "Generated: 0 / 4 Approved". Formula: X / Y where X = visits already created, Y = approved units.
Action	"Generate X Missing Visit" button - Creates unassigned visits for disciplines with unused approved units (only appears for Approved or Partial PAs)

Understanding the "Generate Missing Visit" Button

When It Appears:

• PA status is Approved or Partial
• The discipline has approvedUnits > 0
• The discipline has remaining units (approved - used > 0)

What It Does:

• Creates unassigned visits (no clinician assigned) for the remaining units
• These visits appear in the Schedule Center's "Needs Scheduling" sidebar
• Visits are automatically linked to the PA, so when they're completed, the usedUnits increments

Example:

• PT line: Requested = 12, Approved = 10, Used = 4, Remaining = 6
• Click "Generate 6 Missing Visits"
• System creates 6 unassigned PT visits for this patient
• Now when you complete 1 PT visit, Used becomes 5, Remaining becomes 5

Why This Is Useful:

• Eliminates manual visit creation
• Ensures visits are properly linked to the PA for tracking
• Prevents over-scheduling (can't generate more than approved units)

Quick Actions Section

Two buttons for navigation:

Button	Action
View Source Document	Opens the OASIS assessment that created this PA (in QA Review view)
View Related Visits	Opens the Schedule Center filtered to show this patient's visits

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Updating Prior Authorizations

When you receive approval from insurance, you need to update the PA to record the authorization number and approved units.

Step 1: Open the Update Modal

Click the pencil icon in the Actions column on the PA list, or click the Edit button on the PA details page.

Step 2: Fill in Approval Information

The Update Prior Authorization modal shows:

Top Section: Patient Info

• Patient name displayed (e.g., "Quansa Shoma")

Authorization Number Field

For Billable PAs (with a payer):

• Label: "Authorization Number"
• Required to change status to Approved or Partial
• Placeholder: "Enter authorization number from insurance"
• Example: "123456789" (format varies by payer)

For Non-Billable PAs (no payer):

• Label: "Authorization Number (Optional)"
• Optional - can approve without entering a number
• Helper text: "Non-billable PA (no primary payer). Auth number is optional."

Why Auth Number Is Required for Billable PAs:

• Insurance companies require this number on claims
• Without it, claims will be denied even if the PA is "approved" in your system
• Acts as proof of authorization during audits

Status Dropdown

Select the new status:

Option	When to Use	Requirements
Pending	Still awaiting insurance decision	None
In Progress	Insurance is actively reviewing	None
Approved	Insurance approved all requested units	Requires authorization number (for billable PAs)
Partial	Insurance approved some but not all requested units	Requires authorization number (for billable PAs)
Denied	Insurance denied the request	Requires reason (must explain why it was denied)
Revoked	Insurance revoked a previously approved PA	Requires reason (must explain why it was revoked)
Exhausted	Disabled (auto-managed by system)	Cannot manually set

Note: If you try to select Approved or Partial without entering an authorization number (for billable PAs), the option is disabled with a note: (Requires Auth #).

Reason Field (Conditional)

Only appears when status is Denied or Revoked:

• Required field
• Multiline text area
• Placeholder: "Enter reason for revocation or denial"
• Example: "Insurance denied due to lack of medical necessity documentation."

Why Reason Is Required:

• Provides an audit trail for denied/revoked PAs
• Helps case managers understand what went wrong
• Useful for appeals or future PA requests

Update Approved Units Table

This table allows you to enter the approved units for each discipline:

Column	Description	Editable?
Discipline	Service type (e.g., "Skilled Nursing", "Home Health Aide")	No
Requested	Units requested from insurance (from OASIS)	No
Current Approved	Units currently approved in the system	No (read-only)
Used	Units already used (completed visits)	No (auto-tracked)
New Approved	Editable number field to enter the approved units	Yes - This is what you update

How to Fill This Section:

1. Call the insurance company with the PA request
2. Insurance tells you what they approved for each discipline
3. Enter those numbers in the New Approved column

Example Conversation:

• You: "I'm requesting 10 SN visits and 24 HHA visits."
• Insurance: "We approve 10 SN visits, but only 20 HHA visits."
• You: Enter 10 in the SN "New Approved" field and 20 in the HHA "New Approved" field
• Status: Change status to Partial (because not all disciplines were fully approved: HHA got 20 instead of 24)

Special Case: Extending Approved Units

If a PA is already Approved or Exhausted, you can increase the approved units later:

• Example: PT was approved for 10 visits. Patient needs 5 more sessions.
• Call insurance to request extension
• Insurance approves 5 additional visits
• Update PA: Change PT "New Approved" from 10 to 15
• System automatically recalculates remaining units
• If PA was Exhausted, status automatically changes back to Approved

Step 3: Save Changes

Click "Save Changes" button at the bottom of the modal.

What Happens:

1. PA record is updated in the database
2. If status changed to Approved or Partial:
   • approvedAt timestamp is recorded
   • approvedByUserId is set to the current user
   • Alert appears: "Changing status to 'Approved' will automatically generate unassigned visits for all approved units."
3. If approved units increased for a previously Exhausted PA, status automatically changes to Approved
4. PA list cache is invalidated (list refreshes to show updated data)
5. Success toast: "Prior authorization updated successfully"

Common Update Scenarios

Scenario 1: Full Approval

Situation: Insurance approved all requested units.

Steps:

1. Open PA update modal
2. Enter authorization number (e.g., "AUTH-987654")
3. Change status to Approved
4. For each discipline, enter approved units = requested units:
   • SN: Requested = 10 → New Approved = 10
   • HHA: Requested = 24 → New Approved = 24
5. Save

Result: PA status = Approved, all disciplines have full units available for visit generation.

Scenario 2: Partial Approval

Situation: Insurance approved some disciplines but not others, or approved fewer units than requested.

Steps:

1. Open PA update modal
2. Enter authorization number
3. Change status to Partial
4. Enter approved units:
   • SN: Requested = 10 → New Approved = 10 ✅ (fully approved)
   • PT: Requested = 12 → New Approved = 8 ⚠️ (partially approved)
   • HHA: Requested = 24 → New Approved = 0 ❌ (denied)
5. Save

Result: PA status = Partial, SN and PT lines can generate visits, HHA line has 0 approved so no visits can be generated.

Scenario 3: Denial

Situation: Insurance denied the entire PA request.

Steps:

1. Open PA update modal
2. Change status to Denied
3. Enter reason in the text area (e.g., "Insurance requires face-to-face physician visit within 30 days before services. Patient last saw doctor 45 days ago.")
4. Leave all approved units at 0 (or don't change them)
5. Save

Result: PA status = Denied, no visits can be generated. Case manager must either appeal or create a new care order after addressing the denial reason.

Scenario 4: Extension (Adding Units)

Situation: Patient is progressing well and needs more visits. Insurance approves additional units.

Steps:

1. Open PA update modal for an existing Approved or Exhausted PA
2. For the discipline needing extension:
   • Current Approved = 10
   • Used = 10 (fully exhausted)
   • New Approved = 15 (adding 5 more visits)
3. Save

Result: Status automatically changes from Exhausted to Approved (because remaining units > 0), 5 additional visits can be generated.

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Visit Generation and Tracking

Automatic Visit Generation (On Approval)

When you change a PA status to Approved or Partial for the first time, the system automatically creates unassigned visits for all approved units.

What Gets Created:

• One unassigned visit per approved unit for each discipline
• Visits are linked to the PA via priorAuthorizationId
• Visits appear in the Schedule Center "Needs Scheduling" sidebar
• Visit type is determined by the discipline code (e.g., SN → "Skilled Nursing Visit")

Example:

• PA approved with:
  • SN: 10 units
  • HHA: 20 units
• System creates:
  • 10 unassigned SN visits
  • 20 unassigned HHA visits
• Total: 30 visits appear in Schedule Center

Manual Visit Generation (Per Discipline)

If you need to generate additional visits later (e.g., after extending approved units), use the "Generate X Missing Visit" button on the PA Details page.

Step 1: Identify Disciplines With Remaining Units

• Look at the Service Lines table on PA Details
• Find disciplines where Remaining > 0

Step 2: Click "Generate Missing Visit" Button

• Button text shows how many visits will be created (e.g., "Generate 4 Missing Visits")
• Clicking it triggers visit creation

Step 3: System Creates Visits

• Unassigned visits are created for that discipline
• Success toast: "Visits generated successfully for [Discipline Name]!"
• PA Details page refreshes to show updated generation status

Visit Tracking

As clinicians complete visits, the PA automatically tracks usage:

When a Visit Is Completed:

1. Clinician checks in to visit via mobile app
2. Clinician completes the visit note and marks visit as complete
3. Visit note is reviewed and approved in QA Center
4. Backend increments the PA line's usedUnits by 1
5. System recalculates remaining units
6. If all units are exhausted, PA status automatically changes to Exhausted

Example Timeline:

• Day 1: PA approved - SN: 0 used / 10 remaining
• Day 3: RN completes visit 1 - SN: 1 used / 9 remaining
• Day 7: RN completes visit 2 - SN: 2 used / 8 remaining
• ...
• Day 45: RN completes visit 10 - SN: 10 used / 0 remaining
• System auto-updates: PA status changes to Exhausted

Authorization Alerts on Visits

If you try to create a visit for a patient with an expired, exhausted, or denied PA, the system shows alerts:

Alert Types:

• MISSING_AUTH - Patient has no valid PA, or PA is expired/exhausted/denied
• EXCEEDS_LIMIT - Visit would exceed approved units (shouldn't happen if visits were generated correctly, but possible if manually created)

Where Alerts Appear:

• Visit card on the Schedule Center (icon indicator)
• Visit details page (alert banner at the top)

What to Do:

• Review the PA status
• If expired, request a renewal/extension from insurance
• If exhausted, request additional units
• If denied, address the denial reason and resubmit

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Permissions and Access Control

Required Permissions

Action	Required Permission	Notes
View Prior Authorizations	VIEW_PRIOR_AUTHORIZATIONS	Without this, PA Center menu is hidden
Create Prior Authorizations	System-controlled	PAs are auto-created from OASIS approval (no manual creation permission needed)
Edit/Update PAs	EDIT_PRIOR_AUTHORIZATIONS	Required to open update modal and save changes
View PA Details	VIEW_PRIOR_AUTHORIZATIONS	Can view details page but cannot edit
Generate Visits from PA	CREATE_VISIT + EDIT_PRIOR_AUTHORIZATIONS	Both permissions needed to use "Generate Missing Visit" button

Role-Based Access Examples

Office Manager (Full PA Access)

• Permissions: All PA and visit permissions
• Can Do:
  • View all PAs
  • Update PA status and approved units
  • Generate visits from approved PAs
  • Track authorization usage

Billing Specialist (View Only)

• Permissions: VIEW_PRIOR_AUTHORIZATIONS only
• Can Do:
  • View PA list and details
  • Check authorization numbers for claim submission
  • Track usage and remaining units
• Cannot Do:
  • Update PA status or approved units
  • Generate visits

Clinician (No Access)

• Permissions: None (or only VIEW_SCHEDULE)
• Cannot Access: Prior Authorization Center
• Why: Clinicians don't need PA access; they just complete visits that were already authorized and scheduled

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Best Practices

1. Update PAs Immediately After Insurance Approval

Why:

• Insurance approval phone calls happen in real-time
• Details are fresh in your mind
• Prevents forgetting to record approval

How:

• Keep the PA Center open during insurance calls
• As the insurance rep tells you approved units, enter them directly into the update modal
• Record the authorization number exactly as stated (don't abbreviate or modify)

2. Always Request Authorization Numbers for Billable PAs

Why:

• Required for claim submission
• Insurance may reject claims without a valid auth number
• Acts as proof during audits

How:

• During the insurance call, explicitly ask: "What is the authorization number for this approval?"
• If they don't provide one, ask if they'll send it via email or their portal
• Don't change status to Approved until you have the auth number

3. Monitor PAs Approaching Expiration

Why:

• Services must stop when PA expires (unless renewed)
• Last-minute renewal requests are harder to get approved
• Gaps in service affect patient care continuity

How:

• Check the PA list weekly
• Filter by Approved status
• Sort by end date (soonest first)
• For PAs expiring in next 10-14 days:
  • Contact insurance to request extension or new PA
  • Update the PA with the new end date or create a new PA

4. Generate Visits Immediately After Approval

Why:

• Visits appear in Schedule Center so coordinators can assign clinicians
• Prevents delays in starting patient care
• Ensures visits are properly linked to the PA for tracking

How:

• As soon as you change PA status to Approved, visits are auto-generated
• OR manually click "Generate Missing Visit" buttons for each discipline
• Then go to Schedule Center and assign those visits to clinicians

5. Track Remaining Units Proactively

Why:

• Prevents over-scheduling (trying to provide more visits than approved)
• Alerts you when units are running low so you can request extensions
• Ensures you maximize approved units before they expire

How:

• Check the Service Lines table on PA details regularly
• When remaining units reach 25% of approved (e.g., 2 out of 10 left):
  • Assess if patient needs more visits
  • If yes, call insurance to request extension before units run out
• Don't wait until Exhausted to request more units

6. Document Denial Reasons Thoroughly

Why:

• Helps with appeal preparation
• Prevents repeating the same mistakes on future PAs
• Provides audit trail for compliance

How:

• When entering a denial reason, include:
  • Specific reason stated by insurance
  • Date of denial call
  • Name of insurance rep (if provided)
  • Any instructions for resubmission or appeal
• Example: "Denied on 4/10/26 by rep Sarah. Reason: Requires peer-to-peer review between our MD and insurance MD. Contact insurance at 1-800-XXX-XXXX to schedule review."

7. Use Partial Status Appropriately

Why:

• Accurately reflects mixed approvals (some disciplines approved, others not)
• Prevents confusion about which services are authorized
• Helps billing team know which disciplines to bill

How:

• Use Partial when:
  • Some disciplines are fully approved, others are denied
  • All disciplines are approved, but with fewer units than requested
• Use Approved only when all requested disciplines and units are fully approved

8. Link Non-Billable PAs to Visits Anyway

Why:

• Even if the patient is self-pay or your agency is pre-CCN (not billing yet), tracking visits against a PA helps with:
  • Internal visit planning
  • Future billing setup (when you get your CCN)
  • Reporting and analytics

How:

• When creating a PA for a patient with no payer:
  • Leave authorization number blank (it's optional for non-billable PAs)
  • Change status to Approved even without an auth number
  • Generate visits as normal
  • Track usage to understand service delivery patterns

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Common Scenarios and Solutions

Scenario 1: PA Created but Insurance Hasn't Responded Yet

Situation: OASIS was approved 3 days ago, PA was auto-created with Pending status, but you're still waiting for insurance to call back.

Actions:

1. Check the PA list - Status should be Pending
2. Follow up with insurance if it's been more than 48 hours
3. If insurance is slow, you can change status to In Progress to indicate active follow-up
4. Once approved, update with auth number and approved units

Note: Don't start visits until PA is approved (unless patient agrees to self-pay if insurance denies).

Scenario 2: Insurance Approved Fewer Units Than Requested

Situation: You requested 12 PT visits, but insurance only approved 8.

Actions:

1. Update PA status to Partial
2. Enter auth number
3. Set PT approved units to 8 (not 12)
4. Generate visits - only 8 PT visits will be created
5. After 8 visits are complete, reassess patient's needs:
   • If patient still needs PT, call insurance to request additional units
   • If patient no longer needs PT, PA remains Exhausted for PT line

Best Practice: Don't schedule all 8 visits immediately. Schedule in increments (e.g., first 4 visits), then reassess and schedule next 4 as patient progresses.

Scenario 3: PA Expires Before All Units Are Used

Situation: PA was approved for 20 HHA visits from Apr 1 - June 30. By June 30, only 15 visits were completed. PA status changes to Expired.

Actions:

1. PA status auto-updates to Expired on July 1
2. Remaining 5 units become invalid
3. You have two options:
   • Option A: Request Extension - Call insurance before June 30 to extend the end date
   • Option B: New Authorization - If already expired, request a new PA covering the next period

Prevention: Monitor end dates proactively. Don't wait until the last week to request extensions.

Scenario 4: Patient's Insurance Changes Mid-Episode

Situation: Patient was on Blue Cross, PA was approved. Now patient switched to Medicaid (new payer).

Actions:

1. Update patient's primary payer to Medicaid (in Patient Intake module)
2. Critical: The existing PA remains linked to Blue Cross (can't change payer on existing PA)
3. Create a new care order (or initiate recertification) to generate a new PA linked to Medicaid
4. Old PA with Blue Cross should be marked Revoked or Closed (use update modal, enter reason: "Patient changed insurance to Medicaid")
5. New PA will be created from the recertification OASIS, linked to Medicaid

Why You Can't Change Payer on Existing PA:

• Authorization numbers and approved units are specific to the original payer
• Billing claims will reference the original payer's auth number
• Changing mid-stream creates billing confusion

Scenario 5: All Units Exhausted but Patient Needs More Care

Situation: PT PA approved for 10 visits, all 10 completed, status changed to Exhausted, but patient still needs PT.

Actions:

1. Assess if patient needs more PT (clinician evaluation)
2. Call insurance to request additional units:
   • Provide update on patient's progress
   • Explain why more visits are medically necessary
   • Request specific number of additional visits
3. If insurance approves:
   • Update the PA: Increase PT approved units from 10 to (e.g.) 15
   • Status automatically changes back to Approved
   • Generate 5 additional PT visits
4. If insurance denies:
   • Patient can self-pay for additional visits (not linked to PA)
   • OR appeal the denial
   • OR discontinue PT services

Best Practice: Request extensions before exhausting all units (e.g., when 2 visits remaining).

Scenario 6: Authorization Number is Wrong

Situation: You entered auth number "123456" but insurance says their records show "789012". Claims are being denied.

Actions:

1. Open PA update modal
2. Correct the authorization number field
3. Save changes
4. Resubmit any denied claims with the corrected auth number
5. Alert billing team about the correction

Prevention: Double-check auth numbers during the insurance call. Repeat it back to the rep for confirmation.

Scenario 7: Insurance Revokes a Previously Approved PA

Situation: PA was approved 2 months ago, 5 visits completed, then insurance calls to say patient lost eligibility and PA is revoked retroactively.

Actions:

1. Update PA status to Revoked
2. Enter reason: "Insurance revoked due to patient losing eligibility effective [date]. Called by [rep name] on [date]."
3. System will prevent new visits from being completed against this PA
4. Billing team must:
   • Review claims already submitted for the 5 completed visits
   • Expect denials or clawbacks
   • Work with patient to resolve payment (self-pay or appeal)

Note: This is rare and usually happens due to patient eligibility issues (e.g., insurance lapsed, patient didn't pay premiums).

Scenario 8: PA Automatically Created with No Payer (Non-Billable)

Situation: Patient intake was completed without assigning a primary payer. OASIS approved, PA created with payerId: NULL.

Actions:

1. If patient does have insurance:
   • Go to Patient Intake, assign the primary payer
   • Update PA: Change status to Approved (no auth number needed for now, but you should get one for billing)
   • OR initiate a new recertification to create a new PA linked to the payer
2. If patient is truly self-pay:
   • Leave PA as-is with payerId: NULL
   • Change status to Approved (no auth number required)
   • Generate visits and proceed with self-pay billing workflow

Why This Happens:

• Patient intake allows proceeding without payer assignment (useful for pre-CCN agencies)
• OASIS PA creation logic doesn't block on missing payer; it just sets payerId: NULL

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Troubleshooting

Issue: PA Was Not Auto-Created After OASIS Approval

Possible Causes:

1. OASIS was not actually approved (still in Pending Review or Returned for Correction)
2. Backend service failed during PA creation (check server logs)
3. Care order had no treatment frequency in Plan of Care (all disciplines = 0 visits)

Solutions:

• Verify OASIS status is Approved in QA Center
• Check server logs for errors containing "PriorAuthorization"
• If OASIS has 0 frequency for all disciplines, no PA is needed (no visits to authorize)
• If PA should exist but doesn't, manually check database or contact technical support

Issue: "Generate Missing Visit" Button Doesn't Work

Possible Causes:

1. User lacks CREATE_VISIT or EDIT_PRIOR_AUTHORIZATIONS permission
2. PA status is not Approved or Partial
3. Discipline line has 0 approved units
4. All approved units are already generated (generation status shows "Generated: X / X")

Solutions:

• Verify user permissions in User Roles & Permissions module
• Check PA status - button only works for Approved or Partial PAs
• Verify approved units > 0 for that discipline
• Check generation status - if visits are already generated, button may be disabled or show "All visits generated"

Issue: PA Shows "Exhausted" but Units Remaining > 0

Possible Causes:

• Cron job ran before recent visit completion was processed
• Database inconsistency between PA lines and actual visit counts

Solutions:

1. Refresh the PA details page (F5)
2. Check Service Lines table to confirm used vs approved units
3. If inconsistency persists, contact technical support to reconcile visit counts
4. As a workaround, increase approved units by 1, then decrease back (this triggers status recalculation)

Issue: Cannot Edit PA (Pencil Icon Disabled)

Possible Causes:

1. User lacks EDIT_PRIOR_AUTHORIZATIONS permission
2. PA status is Revoked or Denied (cannot edit these statuses)

Solutions:

• Verify user permissions
• If PA is revoked/denied and you need to change it, you must create a new PA (usually via a new care order/recertification)
• Revoked/denied PAs are intentionally locked to preserve audit trail

Issue: PA Effective Dates Don't Match Care Order Dates

Possible Causes:

• Care order certification period was updated after PA was created
• PA was created from an older OASIS when care order had different dates

Solutions:

• PA dates are set at creation time and don't auto-update if care order dates change
• If PA dates are wrong, you have two options:
  • Option A: Manually adjust via database (requires technical support)
  • Option B: Create a new PA by initiating a new recertification with correct dates
• Best practice: Ensure care order dates are correct before approving the OASIS that creates the PA

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Integration with Other Modules

OASIS Assessments (Source)

• Link: PAs are auto-created when OASIS is approved
• Impact: OASIS Plan of Care frequencies determine requested units for each discipline
• Field Mapping:
  • OASIS SN frequency (e.g., 2x/week for 8 weeks = 16) → PA SN line requested units = 16
  • OASIS effective dates → PA start/end dates

QA Center

• Link: PA creation is triggered in the QA approval workflow
• Impact: If OASIS is returned for correction, PA creation is delayed until re-approval

Schedule Center

• Link: Visits generated from PAs appear in Schedule Center "Needs Scheduling" sidebar
• Impact: When visits are completed, PA usedUnits is incremented
• Authorization Alerts: Visits show MISSING_AUTH or EXCEEDS_LIMIT alerts if PA is invalid

Claims Center

• Link: Authorization number from PA is required on CMS-1500 claim forms (Box 23)
• Impact: Claims without valid auth numbers will be denied by insurance

Patient Module

• Link: PA's payer is populated from patient's primary insurance
• Impact: If patient has no primary payer, PA is created with payerId: NULL (non-billable)

Care Orders Module

• Link: PA is linked to the care order that generated the OASIS
• Impact: If care order is closed, PA should be marked Closed or Revoked

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