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referral-prior-auth-gateway

Referral & Prior Auth Gateway for patient access teams

Work the referral worklist, act on eligibility results, use the payer rules library, build and submit prior authorization requests, and follow each one through pends, decisions and denials.

Foundation2 hr 20 min14 lessonsFor UsersCertificate of completion

Lesson plan (printable)

About this course

The Referral & Prior Auth Gateway sits between your EHR and payers. It checks coverage for each referral or order, works out from the payer rules library whether the payer needs prior authorization, assembles the request from the order and clinical documentation, submits it electronically where the payer accepts it, and tracks every request to a decision. This course teaches the everyday work of the people who keep that process moving: referral coordinators, prior authorization specialists and patient-access leads.

The course follows a referral from the worklist to a decision, in three modules: the worklist and coverage, building and submitting requests, and pends, decisions and follow-up. The examples use fictional patients and payers. Your organization's payer rules, queues, submission routes and settings are configured with your team, so what you see may differ in detail from the examples here.

What you’ll be able to do

  • Explain where the Gateway sits between your EHR, your clearinghouse and payers, and what each role does in it
  • Work the intake worklist by appointment date and move referrals to the right stage
  • Read an eligibility result and decide what to do about inactive coverage, a different payer or a benefit limit
  • Use the payer rules library to decide whether a service needs prior authorization and what the payer asks for
  • Build a complete documentation packet and submit it by the right route, X12 278, payer API or portal hand-off
  • Handle pends and requests for more information, record decisions and act before authorizations expire
  • Follow up a denial with the payer's stated reason, peer-to-peer review or appeal

Skills you’ll gain

  • Referral worklist management
  • Eligibility verification
  • Payer rules and authorization requirements
  • Prior authorization submission
  • Pend and denial follow-up

Before you start

  • You have a Moraph client account and can sign in to the Referral & Prior Auth Gateway with your organization's single sign-on
  • You work in patient access, referrals, scheduling or prior authorization, or support people who do
  • You know the basics of health insurance coverage, such as payers, plans and member IDs
  • Recommended first: Moraph foundations: technology for high-stakes work

Syllabus

3 modules · 9 readings · 1 practical exercise · 4 assessments

  1. Module 1The worklist and coverage

    1. Reading: How the Gateway fits your patient-access workReading · 9 min
    2. Reading: Working the intake worklistReading · 10 min
    3. Reading: Acting on eligibility resultsReading · 10 min
    4. Assessment: Module 1 knowledge checkAssessment · 6 min

  2. Module 2Building and submitting requests

    1. Reading: Using the payer rules libraryReading · 10 min
    2. Reading: Building the documentation packetReading · 11 min
    3. Reading: Submitting the request: X12 278, payer APIs and portalsReading · 12 min
    4. Practical exercise: Practical: prepare an authorization requestPractical exercise · 15 min
    5. Assessment: Module 2 knowledge checkAssessment · 6 min

  3. Module 3Pends, decisions and follow-up

    1. Reading: Pends and requests for more informationReading · 10 min
    2. Reading: Recording decisions and watching expiryReading · 10 min
    3. Reading: Following up denialsReading · 10 min
    4. Assessment: Module 3 knowledge checkAssessment · 6 min
    5. Assessment: Final assessmentAssessment · 15 min

What completion gives you

Complete every lesson and pass each assessment to complete the course. You then get a completion record in My learning, and a certificate of completion you can print or share, with a code anyone can check at academy.moraph.com/verify.

Completion is not certification

Course completion records and certificates of completion show that a person completed a Moraph Academy course. They are not a Moraph certification (which needs the certification exam), a professional license or an accreditation, and they do not authorize anyone to configure, operate, resell or support Moraph products on Moraph’s or anyone else’s behalf.

Course updates

  • Version 1 · · First published.