Lesson plan

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.

Back to the course

Product: referral-prior-auth-gateway
Level: Foundation
For: Users
Total time: 2 hr 20 min
Lessons: 14 in 3 modules
Assessments: 4

Course objectives

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

Before the course

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

Module 1: The worklist and coverage (35 min)

Lesson	Type and time	Learners will be able to	Activity and assessment
How the Gateway fits your patient-access work	Reading 9 min	Describe where the Gateway sits between your EHR, your clearinghouse, payers and scheduling Name the three record types and the stages each one moves through Explain what each patient-access role does and does not do in the Gateway	Reading
Working the intake worklist	Reading 10 min	Open the intake worklist and sort it so the most urgent work comes first Recognize duplicate orders, unmatched appointments and items without an owner Move each referral to the right next stage	Reading
Acting on eligibility results	Reading 10 min	Explain what the X12 270 inquiry and 271 response are and where the result is stored Decide what to do for each eligibility result, from active to not checked Know when to recheck coverage before an appointment	Reading
Module 1 knowledge check	Assessment 6 min	Check your understanding of the worklist, record types, roles and eligibility results	5 questions · pass mark 70% · unlimited attempts

Module 2: Building and submitting requests (54 min)

Lesson	Type and time	Learners will be able to	Activity and assessment
Using the payer rules library	Reading 10 min	Read a payer rule and decide whether a service needs prior authorization Identify the documentation the payer asks for and the preferred submission route Spot a rule that may be out of date and report it to an administrator	Reading
Building the documentation packet	Reading 11 min	Start an authorization request from a referral and check the packet against the payer rule Write a specific documentation request to the ordering clinician's team Apply the minimum necessary standard to what goes in the packet	Reading
Submitting the request: X12 278, payer APIs and portals	Reading 12 min	Explain the three submission routes and when each is used Submit a request and record the payer reference Handle a portal hand-off and a rejected 278 correctly	Reading
Practical: prepare an authorization request	Practical exercise 15 min	Decide from a payer rule whether a referral needs authorization and how to submit it Plan a complete documentation packet and a specific documentation request	Practical exercise with a checklist
Module 2 knowledge check	Assessment 6 min	Check your understanding of payer rules, documentation packets and submission routes	5 questions · pass mark 70% · unlimited attempts

Module 3: Pends, decisions and follow-up (51 min)

Lesson	Type and time	Learners will be able to	Activity and assessment
Pends and requests for more information	Reading 10 min	Explain what a pend is and how it appears in the Gateway Route a payer's request for more information to the person who can answer it Follow up requests with no payer response	Reading
Recording decisions and watching expiry	Reading 10 min	Record an approval with its number, units, dates and restrictions Check that the appointment fits the authorization Act on expiring authorizations and units nearly used	Reading
Following up denials	Reading 10 min	Record a denial with the payer's stated reason and choose a follow-up route with the clinician Recognize denials that point to a process or payer rule problem Know which problems go to Moraph Support and which go elsewhere	Reading
Module 3 knowledge check	Assessment 6 min	Check your understanding of pends, recording decisions, expiry and denial follow-up	5 questions · pass mark 70% · unlimited attempts
Final assessment	Assessment 15 min	Show that you can work a referral from the worklist to a decision and follow-up Apply payer rules, submission routes and denial follow-up to realistic scenarios	12 of 18 questions · pass mark 80% · 3 attempts

Completing the course

Every lesson must be completed: reading lessons are marked complete by the learner, exercises when every checklist item is confirmed, and assessments only when passed. Completing the course issues a certificate of completion with a verification code.