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  1. Module 1: The Landscape of Prior Authorization
    • Section 1.1: The Origins and Purpose of Prior Authorization
    • Section 1.2: Stakeholders and Roles in the PA Ecosystem
    • Section 1.3: Why Prior Authorization Exists: Cost, Safety, and Utilization Control
    • Section 1.4: The Impact of PA on Patient Access and Provider Workload
    • Section 1.5: Regulatory Oversight: CMS, State Boards, and Payers
    • Section 1.6: The PBM’s Role as a Fiduciary for Health Plan Clients
  2. Module 2: Utilization Management & the Role of the PA Specialist
    • Section 2.1: Understanding Utilization Management (UM) Functions
    • Section 2.2: The Prior Authorization Specialist: Roles and Responsibilities
    • Section 2.3: Organizational Models (Pharmacy, Clinic, PBM, Hospital)
    • Section 2.4: Common Career Pathways and Professional Advancement
    • Section 2.5: Core Competencies for Authorization Professionals
  3. Module 3: Insurance Fundamentals & Benefit Structures
    • Section 3.1: Federal Programs: Medicare, Medicaid, and Tricare
    • Section 3.2: Commercial and Exchange Plans Overview
    • Section 3.3: Formularies, Tiers, and Deductibles Explained
    • Section 3.4: Cost-Sharing Models and Coverage Gaps
    • Section 3.5: Key Payer Terminology and Plan Codes
  4. Module 4: Medical vs. Pharmacy Benefit: Coverage Pathways
    • Section 4.1: Distinguishing Between Medical and Pharmacy Benefits
    • Section 4.2: Common Billing Identifiers: J-Codes, NDCs, and HCPCS
    • Section 4.3: How Claims Are Routed and Processed
    • Section 4.4: Payer Decision Logic and Coverage Criteria
    • Section 4.5: Preventing Misrouting and Duplicate Requests
  5. Module 5: Coding & Documentation Essentials
    • Section 5.1: ICD-10: Diagnosis Coding for Medical Necessity
    • Section 5.2: CPT and HCPCS: Service and Supply Codes
    • Section 5.3: Linking Clinical Justification to Payer Requirements
    • Section 5.4: Constructing a Clear and Compliant Narrative
    • Section 5.5: Common Coding Errors and Audit Triggers
  6. Module 6: Understanding the Prescription & Clinical Documentation
    • Section 6.1: The Anatomy of a Prescription
    • Section 6.2: Key Components of Medical Records and Progress Notes
    • Section 6.3: Reviewing Labs, Imaging, and Clinical Notes for PA Data
    • Section 6.4: Locating Supporting Documentation Quickly
    • Section 6.5: Building a Documentation Checklist
  7. Module 7: Patient Eligibility, Verification & Coordination
    • Section 7.1: Insurance Verification: Tools and Portals
    • Section 7.2: Interpreting Eligibility Responses and Benefit Summaries
    • Section 7.3: Coordination with Patient, Prescriber, and Billing Staff
    • Section 7.4: Managing Secondary Insurance and COB
    • Section 7.5: Data Integrity and Case Intake Accuracy
  8. Module 8: Communication Channels & e-Submission Platforms
    • Section 8.1: Communication Methods: Phone, Fax, Portal, and ePA
    • Section 8.2: Overview of Key Platforms (CoverMyMeds, Surescripts, Payer Portals)
    • Section 8.3: Documentation Standards for Communication Logs
    • Section 8.4: Status Follow-Up and Response Time Management
    • Section 8.5: E-Submission Case Simulation
  9. Module 9: Service Line & Specialty Variations
    • Section 9.1: Imaging and Radiology Authorizations
    • Section 9.2: Oncology and Hematology Workflows
    • Section 9.3: Infusion and Injectable Therapy Requests
    • Section 9.4: Durable Medical Equipment (DME) and Supplies
    • Section 9.5: Behavioral Health, PT/OT, and Rehab Services
  10. Module 10: Specialty Medication Authorization
    • Section 10.1: Specialty Drug Landscape and Distribution Models
    • Section 10.2: Biologics, Gene Therapy, and High-Cost Drugs
    • Section 10.3: REMS Programs and Clinical Monitoring Requirements
    • Section 10.4: Documentation for Specialty Approval
    • Section 10.5: Specialty Pharmacy Coordination and Shipment Logistics
  11. Module 11: Out-of-Network Requests & Continuity of Care
    • Section 11.1: Understanding Network Design and Access Barriers
    • Section 11.2: Indications for Out-of-Network Requests
    • Section 11.3: Preparing a Justification Letter and Supporting Docs
    • Section 11.4: Negotiating Single-Case Agreements
    • Section 11.5: Managing Continuity of Care During Transitions
  12. Module 12: Compliance, HIPAA & Audit Preparedness
    • Section 12.1: HIPAA, PHI, and Confidentiality Basics
    • Section 12.2: Fraud, Waste, and Abuse Prevention
    • Section 12.3: Proper Data Storage and Transmission Practices
    • Section 12.4: Internal Audit Preparation and Mock Reviews
    • Section 12.5: Case Documentation Standards
  13. Module 13: Common Coverage Determination Types
    • Section 13.1: Step Therapy and Exceptions
    • Section 13.2: Tier Exception Requests
    • Section 13.3: Quantity Limits and Supply Exceptions
    • Section 13.4: Non-Formulary Drug Requests
    • Section 13.5: Off-Label and Experimental Use Policies
  14. Module 14: Denials: Root Cause Analysis
    • Section 14.1: Common Denial Reasons and Payer Codes
    • Section 14.2: How to Read and Interpret a Denial Letter
    • Section 14.3: Identifying Systemic vs. Case-Specific Issues
    • Section 14.4: Process Improvement for First-Pass Approvals
    • Section 14.5: Preventing Future Denials through Upstream QA
  15. Module 15: Appeals & Peer-to-Peer Strategies
    • Section 15.1: Levels of Appeal: Internal, External, and Independent Review
    • Section 15.2: Writing a Persuasive Appeal Letter
    • Section 15.3: Gathering Missing Evidence and Clinical Justification
    • Section 15.4: Peer-to-Peer Call Preparation and Etiquette
    • Section 15.5: Documenting for the External Review
    • Section 15.6: Case Study: Denial Reversal Success Story
  16. Module 16: Timeframes, Turnaround Rules & Escalations
    • Section 16.1: Regulatory Time Limits (State, CMS, Commercial)
    • Section 16.2: Expedited vs. Standard Processing
    • Section 16.3: Managing Stat Requests and Escalations
    • Section 16.4: Documentation of Delays and Responses
    • Section 16.5: Internal Timeliness Metrics
  17. Module 17: Technology & Automation in Prior Authorization
    • Section 17.1: Electronic Prior Authorization (ePA) Standards
    • Section 17.2: FHIR, X12, and Interoperability Basics
    • Section 17.3: RPA (Robotic Process Automation) in Access Operations
    • Section 17.4: AI Tools for Pre-Check and Predictive Approvals
    • Section 17.5: Balancing Efficiency and Compliance
  18. Module 18: Working with EMRs & EHRs
    • Section 18.1: Common EHR Systems: Epic, Cerner, Meditech, and Allscripts
    • Section 18.2: Extracting Clinical Data Efficiently
    • Section 18.3: Templates and Smart Phrases for PAs
    • Section 18.4: Integrating with Referral and Billing Modules
    • Section 18.5: Data Validation and Error Prevention
  19. Module 19: Interprofessional Collaboration
    • Section 19.1: Communicating Effectively with Prescribers
    • Section 19.2: Partnering with Nurses and Care Managers
    • Section 19.3: Coordination with Billing, Intake, and Appeals Teams
    • Section 19.4: Standardized Communication Templates
    • Section 19.5: Conflict Resolution and Escalation Etiquette
  20. Module 20: Patient Advocacy & Financial Navigation
    • Section 20.1: Overview of Copay Cards and Foundation Assistance
    • Section 20.2: Free Drug Programs and Manufacturer Bridges
    • Section 20.3: Working with Social Workers and Financial Counselors
    • Section 20.4: Ethical Guidelines in Affordability Assistance
    • Section 20.5: Case Management Integration
  21. Module 21: Metrics, Quality & Performance Improvement
    • Section 21.1: Key Metrics: Turnaround Time, Approval Rate, Denial Ratio
    • Section 21.2: Quality Assurance and Process Monitoring
    • Section 21.3: Using Dashboards and Analytics Tools
    • Section 21.4: Continuous Improvement Framework (PDSA, Lean)
    • Section 21.5: Reporting and Presenting Outcomes to Leadership
  22. Module 22: Leadership & Career Development
    • Section 22.1: Transitioning from Coordinator to Supervisor
    • Section 22.2: Leadership and Mentoring Skills in PA Operations
    • Section 22.3: Building and Managing a Team
    • Section 22.4: Coaching for Quality and Efficiency
    • Section 22.5: Strategic Career Planning in Access Services
  23. Module 23: Special Topics & Case Simulations
    • Section 23.1: Oncology Case Simulation: PA for Immunotherapy
    • Section 23.2: Neurology Case: Step Therapy Appeal
    • Section 23.3: Rheumatology Case: High-Cost Biologic
    • Section 23.4: Behavioral Health Case: Non-Formulary Exception
    • Section 23.5: Advanced Exercise: Denial Root-Cause Map
  24. Module 24: The Economics & Strategy of Formulary Management
    • Section 24.1: Introduction to PBM Business Models
    • Section 24.2: The Role of the Pharmacy & Therapeutics (P&T) Committee
    • Section 24.3: Rebates and Net Cost
    • Section 24.4: Health Economics and Outcomes Research (HEOR)
    • Section 24.5: Connecting PA Criteria to Formulary Strategy
  25. Module 25: Clinical Criteria Development & Maintenance
    • Section 25.1: Anatomy of a PA Guideline
    • Section 25.2: Evidence-Based Medicine in Policy
    • Section 25.3: Translating Clinical Nuance into Operational Rules
    • Section 25.4: The Annual Review Cycle
    • Section 25.5: Writing for an Audience
  26. Module 26: Data Analytics & Population Health in Utilization Management
    • Section 26.1: Introduction to PBM Data Sources
    • Section 26.2: Identifying Trends and Outliers
    • Section 26.3: Measuring Program Effectiveness
    • Section 26.4: From Data to Action
    • Section 26.5: Reporting for Client Value
  27. Module 27: The Future of Prior Authorization & Industry Trends
    • Section 27.1: Federal Reforms: Gold Carding and CMS ePA Mandates
    • Section 27.2: State-Level Legislative Changes
    • Section 27.3: Emerging Payer Transparency Requirements
    • Section 27.4: Automation, AI, and Predictive Policy Models
    • Section 27.5: Career Outlook and Professional Opportunities
  28. Module 28: PBM Career Prep & Interview Success
    • Section 28.1: Crafting a “PBM-Ready” Resume
    • Section 28.2: Building Talking Points from CPAP Competencies
    • Section 28.3: Common Interview Scenarios
    • Section 28.4: Mock Interview Script and Confidence Framing
← Previous Section 26.5: Reporting for Client Value
Next Section 27.1: Federal Reforms: Gold Carding and CMS ePA Mandates →
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  • Certified Medication Safety Officer (CMSO)
  • Certified Pharmacy Audit Specialist (CPAS)
  • Certified Pharmacy Data Privacy Officer (CPDPO)
  • Certified Hazardous Drug Handling Pharmacist (CHDHP)
  • Certified USP 800 Compliance Officer (CUCO)
  • Certified Pharmacy Regulatory Specialist (CPRS)
  • Certified Regulatory Affairs Specialist (CRAS)
  • Certified Pharmacovigilance & Safety Officer (CPSO)
  • Certified Compliance Pharmacist – 340B Focus (CCP-340B)
  • Certified Prior Authorization Pharmacist (CPAP)

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