Section 1: Key Metrics: Turnaround Time, Approval Rate, Denial Ratio

21.1.1 The “Why”: From Clinical Practice to Performance Measurement

Throughout your career as a pharmacist, you have been conditioned to measure success through clinical outcomes. Did the patient’s A1c decrease? Is their blood pressure at goal? Was a medication error prevented? These are the tangible, patient-centered results that define excellence in pharmacy practice. They are, and always will be, critically important. However, as you transition into the specialized world of prior authorization, you must adopt a second, parallel language: the language of operational metrics. In this environment, your value is not only measured by your clinical acumen but also by your efficiency, effectiveness, and ability to navigate complex administrative systems with precision and speed.

The phrase “what gets measured, gets managed” is the guiding principle of this module. A PA department that operates without clear, consistent metrics is flying blind. Team members may feel incredibly busy, but they have no objective way to gauge their performance, identify bottlenecks, or demonstrate their value to the broader organization. Leadership, in turn, has no way to justify staffing, invest in new technology, or understand the department’s return on investment. Without data, you are just another cost center. With data, you become a strategic asset.

This section will provide a masterclass on the three foundational pillars of PA performance measurement: Turnaround Time (TAT), Approval Rate, and Denial Ratio. Think of these as the vital signs of your PA operations. TAT is the heart rate—it measures the pace and efficiency of your workflow. The Approval Rate is your efficacy—a measure of how successfully you achieve your primary objective. The Denial Ratio is your diagnostic tool—it reveals where your processes are failing and where opportunities for improvement lie. Mastering the ability to define, calculate, interpret, and act upon these metrics is a non-negotiable skill for a Certified Prior Authorization Pharmacist. It is how you move from being a task-doer to a process-owner, capable of proving your impact in terms that resonate with clinicians, administrators, and the C-suite alike.

21.1.2 Masterclass Deep Dive: Turnaround Time (TAT)

Turnaround Time is the most fundamental measure of operational efficiency. At its core, it answers the simple question: “How long does it take us to get things done?” A consistently low and predictable TAT is a hallmark of a high-performing PA team. It builds trust with providers, who learn they can rely on you for swift action, and it directly impacts patient care by minimizing delays in the start of therapy. However, “TAT” is not a single, monolithic number. To truly understand and manage it, you must deconstruct it into its component parts.

The Components of Turnaround Time

A comprehensive view of TAT requires tracking several distinct intervals. Each one tells a different part of the story and reveals different potential bottlenecks in your process.

Masterclass Table: Deconstructing TAT Metrics

Metric Component	Definition	Calculation	What It Measures	Common Causes for High Values
Receipt-to-Triage TAT	The time from when a request is first received (e.g., fax timestamp, email arrival) to when a team member first opens and assesses it for completeness and urgency.	Triage Timestamp - Receipt Timestamp	The efficiency of your intake process and the speed at which new work is acknowledged and categorized.	Inadequate staffing for intake tasks. “Batch processing” (e.g., only checking the fax machine twice a day). Lack of a centralized, continuously monitored queue.
Triage-to-Submission TAT	The time from the initial triage to the moment the completed PA is successfully submitted to the payer via their preferred portal or fax.	Submission Timestamp - Triage Timestamp	The core work of the PA specialist: gathering clinical data, reviewing criteria, completing forms, and submitting the request.	Delays in receiving necessary clinicals (labs, notes) from the provider’s office. Complex cases requiring extensive chart review. High individual workloads leading to a backlog. Inefficient workflows or unfamiliarity with payer portals.
Submission-to-Determination TAT (Payer TAT)	The time from when the payer acknowledges receipt of the PA to when they issue a final determination (approved or denied).	Determination Timestamp - Submission Timestamp	The payer’s internal processing time. This is largely outside of your direct control but is critical to track.	Payer staffing issues. Statutorily allowed review periods (e.g., 72 hours for urgent, 14 days for standard). System outages at the payer. The request being routed to a clinical pharmacist reviewer at the plan.
Overall Resolution TAT	The “headline” metric. The total elapsed time from the moment the request was first received to the final determination.	Determination Timestamp - Receipt Timestamp	The complete end-to-end patient and provider experience. This is the number that leadership cares about most.	An accumulation of delays in any of the above stages.

Setting Benchmarks and Goals for TAT

“Good” TAT is relative, but industry standards provide a starting point. Your goals should be stratified by urgency, as defined by the payer and clinical need.

• Urgent/Expedited Requests: These are for clinical situations where a delay could seriously jeopardize the patient’s life, health, or ability to regain maximum function. The goal for Overall Resolution TAT should be less than 72 calendar hours, which is the maximum time most regulations allow payers for a determination. A high-performing team aims for an internal Triage-to-Submission TAT of less than 4 business hours.
• Standard/Non-Urgent Requests: These are for non-acute conditions. Payers may take up to 14 calendar days. However, this is far too long for a good patient experience. A strong internal goal for Overall Resolution TAT is 5-7 business days. This requires an efficient internal process with a Triage-to-Submission TAT of 24-48 business hours.

21.1.3 Masterclass Deep Dive: Approval Rate

Approval Rate is the primary metric for measuring a PA team’s effectiveness. It answers the fundamental question: “How often do we succeed in getting the requested therapy for the patient?” While TAT measures speed, Approval Rate measures quality and clinical advocacy. A high approval rate is direct evidence that the team possesses the clinical knowledge and administrative precision to successfully meet payer requirements. It is one of the most powerful indicators of a department’s value.

Calculating and Interpreting Approval Rate

The basic formula is straightforward, but the nuance is in what you include in the denominator.

Approval Rate (%) = $$ \frac{\text{Total Number of Approved PAs}}{\text{Total Number of Resolved PAs (Approved + Denied)}} \times 100 $$

A key consideration is how to handle cases that are withdrawn or canceled. For example, a provider might cancel a PA request because the patient decided on a different therapy. These should typically be excluded from both the numerator and the denominator, as they don’t reflect the team’s ability to secure an approval. A “Resolved PA” is one that has been worked to a final determination from the payer.

What is a “good” Approval Rate? While this varies by specialty and drug mix, a high-performing, mature PA team should consistently achieve an overall approval rate of 90% or higher. A rate below 85% may signal systemic issues with case work-up, clinical documentation, or understanding of payer policies.

The Power of Segmentation: Approval Rate is Not a Monolith

An overall approval rate of 92% sounds great, but it can hide critical performance gaps. To generate actionable insights, you must segment your approval rate data across different dimensions. This is how you move from reporting to analysis.

Masterclass Table: Segmenting Approval Rate Data for Actionable Insights

Segmentation Dimension	Example Data	Potential Insight	Actionable Next Step
By Payer	Payer A: 98% Payer B: 95% Payer C: 78%	The team is highly effective with Payers A and B, but is struggling significantly with Payer C. There is likely a misunderstanding of their specific clinical policies or submission process.	Conduct a deep-dive review of all denials from Payer C in the last quarter. Develop a “Payer C Specific” job aid or training session for the team. Request a meeting with a provider relations representative from Payer C to clarify policies.
By Drug/Drug Class	Oncology Drugs: 95% Cardiology Drugs: 93% GLP-1 Agonists: 65%	The team is adept at complex oncology PAs, but is facing major headwinds with weight loss or diabetes medications. This is likely due to very strict step-therapy or comorbidity requirements from payers.	Create a master grid of GLP-1 criteria for your top 5 payers. Develop template appeal letters that specifically address common GLP-1 denial reasons (e.g., failure of metformin, specific A1c levels).
By Specialist/Team Member	Specialist 1: 96% Specialist 2: 94% Specialist 3: 82%	Specialist 3 may need additional training, be handling a more difficult caseload, or may have a workflow issue. This is a coaching opportunity, not a punitive measure.	Manager to perform a case review with Specialist 3 to identify patterns. Implement a peer-mentoring program where Specialist 1 shares best practices with Specialist 3. Review Specialist 3’s caseload for unusual complexity.

21.1.4 Masterclass Deep Dive: Denial Ratio & Root Cause Analysis

While Approval Rate measures your successes, Denial Ratio and its underlying reasons are your greatest source of learning and improvement. A denial is not just a failure; it is a data point. It is a message from the payer telling you precisely where your submission fell short. Your goal is to become an expert at translating these messages into process improvements. The fundamental question to answer is: “When we fail, why do we fail?”

A Taxonomy of Denials: Not All Denials Are Created Equal

The first step in effective denial management is to stop thinking of “denied” as a single outcome. You must categorize denials to understand their root cause. Broadly, they fall into three categories.

From Denial Data to Action Plan

Tracking your denials by category is the foundation of continuous quality improvement (which we will cover in Section 4). The process involves capturing the specific reason for every denial and using that data to inform changes in your workflow, tools, and training.

Masterclass Table: Denial Root Cause Analysis and Action Planning

Common Denial Reason (from Payer)	Denial Category	Potential Root Cause(s)	Corrective Action Plan
“Patient not eligible on date of service.”	Administrative	Staff is not verifying insurance eligibility at the start of every case; patient’s coverage may have termed or changed.	Modify workflow: Make “verify active eligibility” the mandatory first step in the process. Create a job aid on how to use the payer portal’s eligibility check tool.
“Clinical information submitted does not support medical necessity. Patient has not failed preferred alternative X.”	Clinical	The submitting specialist did not adequately document the contraindication or intolerance to the required step therapy agent (Alternative X).	Develop a drug-specific “smart sheet” for the clinical team that prompts for details on step therapy failures. Draft a template appeal letter that focuses on documenting intolerance (e.g., “Patient tried metformin, which resulted in severe gastrointestinal distress, as documented in the office note on [date]”).
“Requested medication is a formulary exclusion.”	Contractual	The provider has prescribed a medication that the patient’s employer has explicitly excluded from the benefit plan to control costs.	Immediately pivot the conversation with the provider from a standard PA to a “formulary exception request.” Proactively identify the covered therapeutic alternatives on the patient’s formulary and present them to the provider. Manage patient/provider expectations that this will be a difficult and lengthy process to overturn.

21.1.5 The Performance Triangle: Balancing Speed, Quality, and Efficacy

It is a common mistake to focus on improving one metric in isolation. A truly high-performing team understands that TAT, Approval Rate, and Denial Ratio are deeply interconnected. Pushing too hard on one can have unintended negative consequences on the others. The goal is to find a sustainable balance that optimizes the entire system, not just one component.