CPAP Module 6, Section 5: Building a Documentation Checklist
MODULE 6: UNDERSTANDING THE PRESCRIPTION & CLINICAL DOCUMENTATION

Section 6.5: Building a Documentation Checklist for Bulletproof Submissions

Translating Ambiguous Payer Policy into an Actionable, Evidence-Based Workflow.

SECTION 6.5

Building a Documentation Checklist

From Passive Reviewer to Proactive Case Architect: The Pharmacist’s Most Powerful Tool.

6.5.1 The “Why”: The Checklist as Your Architectural Blueprint

In your pharmacy training, you mastered the art of systematic verification. Every prescription that crosses your path is subjected to a rigorous, almost subconscious, mental checklist: Is the patient correct? Is the drug right? Is the dose safe? Is the sig clear? This instinct for systematic review is the bedrock of medication safety and is your most transferable skill in the world of prior authorization. However, in this new domain, your checklist must evolve from a rapid mental scan into a comprehensive, written blueprint for constructing a compelling clinical case.

A prior authorization submission is not merely a collection of documents; it is a structured argument. It is a narrative that must prove, with objective evidence, that the requested therapy is not just beneficial, but medically necessary according to a specific, often convoluted, set of rules. Simply reacting to a payer’s questions or passively attaching records to a form is a recipe for frustration and denial. This approach positions you as a clerk. The professional PA pharmacist, by contrast, acts as an architect. You begin with the end in mind—an approved submission—and then meticulously design and build the case, piece by piece, using a detailed blueprint: your documentation checklist.

This checklist is far more than a to-do list. It is the single most powerful tool for ensuring efficiency, accuracy, and, ultimately, success. It transforms an overwhelming sea of clinical data into a manageable, structured workflow. It allows you to anticipate the payer’s every requirement before they ask, to identify gaps in documentation early, and to communicate with providers with surgical precision. By mastering the art of building and utilizing these checklists, you shift from a passive reviewer of information to the active architect of an undeniable clinical case. You are no longer just finding information; you are strategically assembling evidence to win.

Pharmacist Analogy: The Tax Audit Defense

Imagine you are a highly skilled tax accountant, and your most important client is facing a complex IRS audit. The IRS sends a notice requesting documentation to support a series of deductions. This notice is the payer’s prior authorization request.

The novice accountant might simply react. They would read the first request, find a corresponding receipt, send it, and wait for the next question. This is a slow, painful, and often unsuccessful process. But you are a professional. Your first step is not to find a single receipt. Your first step is to pull out the official IRS tax code—the payer’s clinical policy—and a blank legal pad. You then create your own internal, master documentation checklist.

Your checklist is not just a copy of the IRS’s questions. It’s a comprehensive blueprint for the entire defense. It has sections for “Proof of Business Expense,” “Capital Gains Verification,” “Charitable Contribution Records,” and so on. For each item on your checklist, you list the exact type of document needed (e.g., “canceled check for software purchase,” “brokerage statement from Dec 31st,” “signed donation letter from charity”).

You then use this checklist to systematically gather every piece of evidence from your client’s files. The checklist reveals gaps instantly—”Ah, we’re missing the mileage log for the third quarter.” This allows you to proactively contact your client with a specific, targeted request, rather than a vague “I need more stuff.”

When you finally submit the response to the IRS, you are not just sending a pile of receipts. You are sending a perfectly organized, indexed portfolio where every single potential question has been anticipated and answered with clear, undeniable evidence. Your checklist was the architectural blueprint that allowed you to build this bulletproof case. This is the exact role and power of a documentation checklist in prior authorization.

6.5.2 Deconstructing the Source Material: How to Read a Payer Policy

You cannot build an effective checklist without first knowing how to read the complex, and often intentionally ambiguous, language of a payer’s clinical policy document. These documents are the “tax code” of prior authorization. They are dense, legalistic, and packed with terminology that requires translation into clear, actionable tasks. Your first skill is to become an expert translator, breaking down payer policy into its fundamental components.

A typical policy document is structured into several key sections: a list of covered indications, criteria for initial approval, criteria for continuation of therapy, and non-covered indications. Your job is to dissect the “Criteria for Initial Approval” section with forensic detail, as this is where the core requirements for your checklist will be found. You are not just reading for comprehension; you are hunting for specific, verifiable data points.

Clinical Pearl: Keyword Hunting in Payer Policies

When reviewing a new policy, train your eyes to immediately scan for “action verbs” and “quantifiable metrics.” These are the words and numbers that will form the backbone of your checklist. Look for phrases like:

  • “Diagnosis confirmed by…”
  • “Patient has failed a trial of…”
  • “Contraindication to…”
  • “Lab value of…” (e.g., A1c >, LVEF <)
  • “Score of…” (e.g., DAS28 >, PHQ-9 >)
  • “Must be prescribed by a…”
  • “Within the last X months…”

Each of these phrases is a direct instruction that can be converted into a concrete checklist item. Highlighting these as you read is an excellent way to begin building your checklist structure.

Masterclass Table: Translating Payer Language into Actionable Checklist Items

The following table demonstrates how to translate common, often vague, phrases from payer policies into the specific, evidence-based checklist items you need to build your case.

Payer Policy Phrase What They’re Really Asking For Generated Checklist Item(s)
“Failure of two preferred alternatives” “Show me proof that the patient took two cheaper drugs from our formulary for a reasonable amount of time and that they either didn’t work or caused a significant side effect.”
  • ☑ Locate pharmacy fill history for [Preferred Drug #1] showing at least a 30-day supply dispensed.
  • ☑ Locate provider note documenting lack of efficacy or a specific adverse event for [Preferred Drug #1].
  • ☑ Locate pharmacy fill history for [Preferred Drug #2] showing at least a 30-day supply dispensed.
  • ☑ Locate provider note documenting lack of efficacy or a specific adverse event for [Preferred Drug #2].
“Objective evidence of disease progression” “I don’t trust subjective complaints. Show me a test, a scan, or a number that proves the patient’s condition is worsening on their current therapy.”
  • ☑ Find and compare imaging report (e.g., MRI, CT) from [Date 1] vs. [Date 2].
  • ☑ Find and compare relevant lab values from [Date 1] vs. [Date 2].
  • ☑ Locate progress note documenting a decline in a standardized clinical metric (e.g., worsening 6-minute walk test).
“Patient has a documented contraindication to the preferred agent” “Prove to me that giving the cheaper drug would be unsafe for this specific patient. This can’t be a minor side effect; it must be a recognized contraindication.”
  • ☑ Search patient’s problem list for specific ICD-10 code (e.g., severe renal impairment for an NSAID).
  • ☑ Locate lab report showing a value that meets the contraindication criteria (e.g., CrCl < 30 mL/min).
  • ☑ Find specialist note explicitly stating “[Preferred Drug]” is contraindicated due to a specific condition.
“Must be prescribed by a specialist” “We will only pay for this high-cost drug if an expert in the field (e.g., a cardiologist, oncologist) has determined it is necessary.”
  • ☑ Verify the specialty of the prescribing provider in the EMR or NPI database.
  • ☑ Confirm the prescription is signed by the specialist, not a primary care provider.
“Patient has severe disease” “This drug is only for the sickest patients. Provide the specific, objective data points that meet our definition of ‘severe’.”
  • ☑ Locate lab result confirming value is within the “severe” range (e.g., A1c > 9%).
  • ☑ Locate echocardiogram report confirming LVEF is below the “severe” threshold (e.g., < 30%).
  • ☑ Locate provider note documenting a disease activity score that qualifies as “severe” (e.g., DAS28 > 5.1).
The Peril of Vague and Subjective Criteria

Payers often use subjective terms like “clinically appropriate,” “patient intolerance,” or “inadequate response.” These are the most challenging criteria because they are open to interpretation. When you see these terms, your job is to find objective data that supports the subjective claim.

  • If the policy says “intolerance,” don’t just accept a note that says “patient couldn’t tolerate.” Your checklist item should be: “☑ Find progress note detailing the specific side effect, its severity, and any interventions tried to manage it (e.g., dose reduction).”
  • If the policy says “inadequate response,” your checklist item should be: “☑ Locate objective evidence of continued disease activity despite therapy (e.g., persistently elevated inflammatory markers, provider note stating ‘patient still has 6 swollen joints’).”

Always translate subjective payer language into a hunt for the most objective evidence possible. This is how you prevent a denial based on interpretation.

6.5.3 The Four Pillars of a Bulletproof Checklist: A Universal Template

While every drug and every policy is unique, the fundamental structure of a successful PA submission is remarkably consistent. You can create a universal checklist template based on four core pillars. This framework ensures that you never miss a critical piece of information, from the basic administrative details to the most complex clinical data.

Pillar 1: Demographics & Administrative Data

This is the foundation. Errors here lead to instant technical denials before a clinical reviewer even sees the case. It’s the equivalent of spelling the name wrong on a prescription. Get this 100% right, every time.

Pillar 2: Diagnostic Confirmation

This pillar establishes the “what” and “why.” You must provide undeniable proof that the patient has the specific condition for which the drug is FDA-approved and covered by the plan.

Pillar 3: The Core Clinical Criteria

This is the heart of the submission. Here, you will prove, point-by-point, that the patient meets every single clinical requirement outlined in the payer’s policy, from step-therapy to specific lab values.

Pillar 4: The Request & Attestation

This is the final step, detailing exactly what is being requested. It includes the drug, dose, quantity, and the necessary provider information to make the submission official.

Masterclass Table: The Universal Checklist Template

Use this table as your starting point for any prior authorization. Customize the “Core Clinical Criteria” section based on the specific policy you are working with.

Pillar Checklist Item Where to Find the Evidence (Common Sources)
Pillar 1: Demographics & Admin ☑ Patient Full Name & DOB EMR Face Sheet, Prescription
☑ Insurance Plan Name, ID & Group # EMR Insurance Tab, Eligibility Check Software
☑ Prescribing Provider Name & NPI Prescription, EMR Provider Profile
☑ Servicing Provider/Facility Name & NPI (if different) Prescription, Clinic Notes
☑ Pharmacy Name & NCPDP/NPI Dispensing System, E-Prescription Data
Pillar 2: Diagnostic Confirmation ☑ Primary ICD-10 Code Matching the Requested Indication Prescription, Provider Progress Notes (Assessment & Plan)
☑ Date of Initial Diagnosis Initial Consult Note, Problem List
☑ How Diagnosis was Confirmed (e.g., lab, imaging, biopsy) Pathology Reports, Imaging Reports, Lab Results Tab
☑ Name & Specialty of Diagnosing Provider Initial Consult Note, Referral Records
Pillar 3: Core Clinical Criteria (Example Categories) ☑ Step-Therapy: Evidence of trial/failure/contraindication for [Preferred Drug 1] Pharmacy Fill History, Progress Notes, Allergy List, Problem List
☑ Clinical Parameters: Objective lab/test result meeting criteria (e.g., A1c > 8%) with date. Lab Results Tab, Imaging Reports, Procedure Notes
☑ Disease Severity: Documentation of symptoms or scores meeting “severe” definition. Progress Notes (HPI, Physical Exam), Standardized Score Flowsheets
☑ Continuation of Therapy: Evidence of positive clinical response to the medication. Follow-up Progress Notes, Improvement in Labs/Scores
Pillar 4: The Request & Attestation ☑ Medication Name, Strength, and Formulation Prescription
☑ Dosing Instructions (SIG) Prescription
☑ Quantity Requested & Days’ Supply Prescription
☑ Date of Prescriber’s Signature / Attestation Prescription, PA Request Form

6.5.4 Masterclass in Action: Building Checklists for High-Cost Drugs

Theory is valuable, but practice is essential. In this section, we will apply the Four Pillar framework to build detailed, real-world checklists for three common classes of high-cost specialty drugs. These examples will serve as your guide to transforming dense policy into a practical workflow.

Example 1: A PCSK9 Inhibitor (e.g., Repatha)

PCSK9 inhibitors are highly effective but expensive medications for hypercholesterolemia. Payers scrutinize these requests to ensure they are used only in the highest-risk patients who have failed standard therapy. Let’s analyze a typical policy and build our checklist.

Fictional Payer Policy: “CardioCare Plan – PCKS9 Inhibitors”

Initial approval for evolocumab (Repatha) may be granted for 12 months when all of the following criteria are met:

  1. Patient has a diagnosis of clinical Atherosclerotic Cardiovascular Disease (ASCVD) OR Familial Hypercholesterolemia (FH).
  2. Patient is on a maximally tolerated dose of a high-intensity statin (atorvastatin 40-80mg, rosuvastatin 20-40mg) for at least 3 months, OR has a documented contraindication.
  3. Patient’s most recent LDL-C, taken while on the statin therapy, remains > 70 mg/dL. The lab result must be dated within the last 90 days.
  4. The prescription is written by or in consultation with a cardiologist or endocrinologist.
Repatha PA Checklist (Based on CardioCare Policy)
Pillar Checklist Item Evidence Needed & Location
Admin ☑ All Pillar 1 items (Name, DOB, Insurance, etc.) EMR Face Sheet, Rx
Diagnosis ☑ Criterion 1: Diagnosis of ASCVD or FH. ASCVD: Look for ICD-10 codes for MI (I21), Stroke (I63), CABG/stent history (Z95) in the Problem List or Surgical History.
FH: Look for ICD-10 code E78.01 in Problem List or specific mention in cardiology/lipidology notes.
☑ Date of ASCVD event or FH diagnosis. Hospital discharge summaries, specialist consult notes.
Clinical Criteria ☑ Criterion 2a (Statin Trial): Fill history showing at least 90 days of atorvastatin (40/80mg) or rosuvastatin (20/40mg). Pharmacy fill history (PBM portal or patient report).
☑ Criterion 2b (Statin Intolerance): Progress note detailing a specific, clinically significant side effect (e.g., myalgia with elevated CK) and why a lower dose or alternative statin is not possible. Specialist progress notes.
☑ Criterion 3: LDL-C lab result > 70 mg/dL. Lab results tab.
☑ Criterion 3 (cont.): Date of the LDL lab result is within the last 90 days AND the patient was on the high-intensity statin when it was drawn. Verify lab date. Cross-reference with medication list and fill history to confirm concurrent statin therapy.
Request ☑ Criterion 4: Prescriber is a Cardiologist or Endocrinologist. Verify provider specialty in EMR.
☑ All Pillar 4 items (Drug, Sig, Qty, etc.) Prescription.

Example 2: A Biologic for Rheumatoid Arthritis (e.g., adalimumab)

Biologics for autoimmune conditions like RA have transformed patient care, but their high cost comes with stringent PA requirements. Payers focus on ensuring conventional, less expensive therapies have been tried first.

Fictional Payer Policy: “ImmunoRight Plan – TNF inhibitors”

Initial approval for adalimumab (Humira) may be granted for 6 months when all of the following criteria are met:

  1. Patient has a diagnosis of moderate to severe Rheumatoid Arthritis (RA), confirmed by a rheumatologist.
  2. Patient has tried and failed a 3-month trial of methotrexate at a dose of at least 15 mg/week, unless contraindicated.
  3. Recent clinical documentation (within 6 months) shows continued disease activity, defined as a DAS28 score > 3.2.
  4. Patient has had a negative Tuberculosis (TB) test within the 12 months prior to initiating therapy.
Humira PA Checklist (Based on ImmunoRight Policy)
Pillar Checklist Item Evidence Needed & Location
Admin ☑ All Pillar 1 items. EMR Face Sheet, Rx
Diagnosis ☑ Criterion 1: Diagnosis of RA (ICD-10 M05 or M06). Problem List, Rheumatology consult notes.
☑ Criterion 1 (cont.): Diagnosis was made or confirmed by a Rheumatologist. Find initial rheumatology consult note in the EMR.
Clinical Criteria ☑ Criterion 2 (MTX Trial): Fill history showing at least a 90-day supply of methotrexate. Pharmacy fill history.
☑ Criterion 2 (MTX Dose): Progress notes or medication history confirming the dose was titrated to at least 15 mg/week. Rheumatology follow-up notes are the best source for this.
☑ Criterion 2 (MTX Failure): Note from rheumatologist documenting lack of efficacy (e.g., “patient continues to have multiple swollen/tender joints despite MTX”). Rheumatology follow-up notes.
☑ Criterion 3: A documented DAS28 score > 3.2. Look for a “Flowsheets” tab in the EMR where structured data like disease activity scores are often tracked. Also found in the body of rheumatology notes.
☑ Criterion 4: A negative TB test result (e.g., PPD skin test or Quantiferon Gold blood test). The collection date must be within the last 12 months. Lab results tab or Procedure notes.
Request ☑ All Pillar 4 items. Prescription.
The Methotrexate Dosing Gotcha

A common reason for denial in RA cases is an inadequate methotrexate trial. Payers are very specific. A trial of 7.5 mg weekly for 3 months will not suffice if the policy specifies a target dose of 15 mg. Your checklist must be precise: it’s not just about proving the patient took the drug, but that they took it at the right dose for the right duration. Always hunt for the note where the rheumatologist documents the target dose and the patient’s response at that dose.

6.5.5 Beyond the Document: The Dynamic Checklist and Workflow Integration

A checklist should not be a static piece of paper that gets filed away. It is a living, dynamic tool that guides your entire workflow, from initial case review to final submission and even communication with the provider’s office. It structures your work, enhances your efficiency, and empowers you to be a more effective advocate for the patient.

Think of your checklist as the central dashboard for each PA case. As you find each piece of evidence in the EMR, you “check it off,” either digitally or on paper. This process immediately highlights what’s missing. The true power of the checklist is realized when you use these identified gaps to guide your communication. Instead of sending a vague, inefficient request to a provider’s office like, “I need more clinical information for the Humira PA,” you can be surgically precise.

The PA Pharmacist’s “Gap Analysis” Communication Script

Once your initial chart review and checklist are complete, use this framework to communicate with the provider’s Medical Assistant (MA) or nurse. This demonstrates professionalism and respect for their time.

The Script: “Hi [MA’s Name], this is [Your Name], the pharmacist working on the Humira prior authorization for [Patient Name]. I’ve completed a full review of the chart to build the case for the insurance company, and it looks very strong. I have successfully located the rheumatology notes, the methotrexate trial history, and the negative TB test. To make the submission complete, I just need to locate one final piece of information: the policy requires a recent disease activity score, like a DAS28, from the last few months. Could you point me to where I might find that in the record, or could you ask the provider to document it in a quick addendum? Once I have that, I can send this off. Thank you!”

This approach accomplishes several key things:

  • It shows you have done your homework and are not wasting their time.
  • It clearly states what you have already found, preventing them from sending duplicate information.
  • It identifies the exact missing piece of data required.
  • It makes the “ask” small, specific, and actionable.

Ultimately, integrating the checklist into your daily workflow transforms you from a processor of requests into a manager of clinical cases. You take control of the narrative, build a logical and evidence-based argument, and communicate with clarity and purpose. It is the single most important habit to develop for a successful and fulfilling career as a Certified Prior Authorization Pharmacist.