Chapter 26: Prior Authorizations
Chapter Overview
What You'll Learn:
- How to open Prior Authorizations
- How PAs are created (QA episode activation — not a blank Create button)
- KPI cards and list columns
- Authorization kinds (UM / Service Authorization / Both)
- Hour vs visit unit budgets
- Medicare PDGM vs unit-based Medicaid behavior
- Billing-only visibility
Path: Sidebar → Billing & revenue → Prior Authorizations → /dashboard/prior-authorizations
Billing-only: hidden.
Text-only.
26.1 What You See
- Title: Prior Authorizations
- Subtitle: Manage insurance authorizations and track approved units
KPI cards:
- Total PAs · Pending Approval · Approved · Expiring Soon · Expired · Exhausted · Denied/Revoked · Total Units (used • remaining)
Filters: Search (patient / auth # / payer) · Status · Patient
Table columns: Patient · Payer · Auth # · Effective Dates · Units · Status · Actions
Empty auth #: Not assigned.
Units display like {used} / {approved} used with remaining, or Exhausted.
Hours show as N hr / N hrs; visits as N visit / N visits.
Multi-discipline lines may say {n} disciplines — hover for detail.
Flag: Non-billable visits may appear when visits are forced outside auth.
List actions: View Details · Edit (blocked if Denied / Revoked).
There is no Create PA button on this list. Prior Authorizations are created by the system when QA Approve & Finalize activates an episode (SOC / ROC / Recert). Staff edit and approve the auto-created row (auth #, units, dates, status).
26.2 How a PA Is Created
- Clinician completes SOC / ROC / Recert (OASIS or Non-OASIS).
- QA Approve & Finalize runs episode activation (Chapter 22).
- Betasky creates a PA from Summary of Care frequencies (lines + scheduling blueprint).
- Default status is usually Pending with 0 approved units — except Medicare PDGM (below).
Detail page (/dashboard/prior-authorizations/:id): titles such as Service Authorization Details / UM Prior Auth Details; Edit; per-line Schedule…; fax packet/form actions when Communications is available; used/scheduled visit drill-downs.
26.3 Authorization Kinds
| Kind (internal) | Chip / label |
|---|---|
| UM | UM Prior Auth |
| SERVICE_PLAN | Service Authorization |
| BOTH | Both |
Edit budgets may show Hour budget and/or Visit budget.
26.4 Statuses
Chips / filters include: Pending · In Progress · Approved · Partial · Denied · Expired · Exhausted · Revoked
| Status | Typical meaning |
|---|---|
| Pending | Created; waiting for auth # / approved units |
| Approved / Partial | Ready to schedule against (Schedule on detail) |
| Exhausted | Used units reached approved units on all lines |
| Expired | Past end date (system updates approved/partial rows) |
| Denied / Revoked | Not usable; edit blocked |
Scheduling visits from the PA detail is offered for Approved / Partial only.
26.5 Medicare PDGM vs Unit-Based Medicaid
| Medicare PDGM | Unit-based Medicaid / many MCOs | |
|---|---|---|
| On QA Approve | PA is typically auto-approved (approved units = requested) for operations | PA stays Pending until a biller sets auth # / approved units / status |
| Claim model | HIPPS / 30-day periods in Ready for Billing — not driven by UM service-plan unit ledger | Claims and visit PA checks use service-plan / UM rules and linked PA units |
| Visit generation | Visits are not auto-created on approve — schedule from PA detail or Schedule Center | Same — schedule after Approved/Partial |
26.6 How PAs Affect Billing & Scheduling
- Ready for Billing / claim submit can block when auth is missing or limits exceeded (Chapter 27).
- Hour-based HHA scheduling counts planned hours against hour PA budgets (Chapter 25).
- Non-OASIS SOC/recert episodes may force non-billable visits until policy allows billing.
- Flag links such as Non-billable visits explain when visits fall outside auth.
26.7 Common Mistakes
- Looking for Create PA on the list — PAs come from QA episode activation; edit the pending row.
- Expecting Medicaid to allow claims while PA is still Pending — set approved units / status first.
- Confusing Medicare PDGM (auto-approve + HIPPS claims) with unit-based Medicaid (manual auth + unit ledger).
- Trying to schedule from a Denied / Revoked / Pending PA — Schedule needs Approved or Partial.
26.8 Quick Checklist
- Active / Approved PAs for payers that require them
- Correct kind (UM / Service / Both)
- Auth # and approved units entered for unit-based payers
- Hour vs visit budgets match the benefit
- Expiring Soon / Exhausted reviewed regularly