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CPAP Certification Program
Module 7: Patient Eligibility, Verification & Coordination
The Front Door of Prior Authorization: Ensuring a Solid Foundation for Every Case.
Before the Clinical Case, Comes the Administrative Foundation
As an experienced pharmacist, you are an expert at the “front-end” of prescription processing. You instinctively know how to input patient data, interpret basic insurance rejections, and troubleshoot common claim submission errors. This is the reactive, point-of-sale verification that keeps a pharmacy running.
This module elevates that skill set from a reactive task to a proactive, investigative discipline. In the world of high-cost specialty medications, we cannot afford to discover a patient’s coverage is inactive or their PBM is different *after* we have already spent hours building a complex clinical case. The work of eligibility and benefits verification is the critical “measure twice, cut once” foundation of the entire prior authorization process. It is the methodical, upfront work that prevents catastrophic wasted effort down the line.
Here, you will learn to think like a logistics expert and a communications hub. You will master the tools and portals to confirm every detail of a patient’s coverage before the clinical review begins. You will learn to coordinate with patients, providers, and billing staff to ensure data integrity and to manage complex scenarios like Coordination of Benefits (COB). Mastering these foundational skills is the key to operational excellence, transforming you into a truly efficient and effective PA specialist.
Your Guide to a Flawless Intake Process
This module will provide a systematic framework for verifying every administrative and logistical detail of a case before the deep clinical work begins.
Insurance Verification: Tools and Portals
A practical guide to the essential online portals and third-party software used to perform real-time eligibility checks, identify the correct PBM, and download benefit summary documents.
Interpreting Eligibility Responses and Benefit Summaries
Learn to decode the language of eligibility files, identifying key information like active/inactive status, plan-specific deductibles, out-of-pocket maximums, and formulary details.
Coordination with Patient, Prescriber, and Billing Staff
A masterclass in communication, providing scripts and workflows for efficiently gathering missing information, clarifying discrepancies, and ensuring all stakeholders are aligned.
Managing Secondary Insurance and COB
A deep dive into the complexities of Coordination of Benefits (COB), learning how to identify primary vs. secondary payers and navigate the submission process for patients with multiple insurance plans.
Data Integrity and Case Intake Accuracy
Learn the best practices for initial case setup, ensuring that every piece of demographic, insurance, and clinical data is accurately entered to prevent downstream errors and denials.
