CPAP Module 8, Section 4: Status Follow-Up and Response Time Management
MODULE 8: COMMUNICATION CHANNELS & E-SUBMISSION PLATFORMS

Section 4: Status Follow-Up and Response Time Management

The Art of Proactive Persistence: Turning Waiting Time into Working Time.

SECTION 8.4

The Closed Loop: Mastering the Follow-Up Cadence

Transforming Passive Waiting into Active Case Management.

8.4.1 The “Why”: Submission is the Starting Line, Not the Finish Line

In a traditional pharmacy workflow, a task is often “done” when you hit the send button. You send the refill request. You send the claim to the PBM. You send the order to the wholesaler. The system is designed for a binary response: success or failure. The prior authorization process fundamentally breaks this model. Submitting a PA is not the end of a task; it is the beginning of a monitored clinical event. A submitted PA that is not tracked is a prescription abandoned in a clinical and administrative limbo.

The failure to systematically follow up on pending PA requests is the single most common point of failure in the entire access journey. It is the primary driver of unnecessary delays in therapy, patient frustration, and provider burnout. Proactive follow-up is not “nagging” or “pestering”; it is a core professional responsibility. It is the act of closing the communication loop. It is the mechanism by which you, the pharmacist, take ownership of the case from initiation to final determination. Waiting passively for a fax or a portal update is an abdication of this responsibility. True case management means actively monitoring your pending cases, understanding their status, and intervening precisely when they stall.

This section is designed to instill the discipline and strategy of professional follow-up. We will deconstruct the often-cryptic status indicators you will encounter and translate them into actionable intelligence. We will establish a clear, evidence-based framework for a follow-up cadence—a rhythm of strategic touchpoints that ensures no case is ever forgotten. Finally, we will build an escalation playbook, teaching you not just how to follow up, but how to powerfully escalate a case when it becomes clear that the standard process is failing. Mastering this proactive mindset is what separates a PA processor from a PA specialist. It is how you convert waiting time into working time and ensure that your clinical efforts result in timely patient care.

Retail Pharmacist Analogy: Managing the Refill Authorization Queue

Think about the “pending refill authorizations” queue in your pharmacy dispensing system. This is a perfect microcosm of a PA work queue. When a patient requests a refill for a prescription with no refills remaining, you don’t just tell them, “We’ll see what happens,” and send them away.

Instead, you engage in a sophisticated, multi-step follow-up process.

  • Initiation: You send an electronic or fax request to the prescriber’s office. This is identical to submitting a PA.
  • Initial Monitoring (The 24-Hour Rule): Your pharmacy has a policy. You don’t let a request sit for more than 24 hours without action. The next day, a technician or pharmacist reviews the pending queue. This is your first follow-up.
  • Intervention: For requests that are still pending after 24 hours, you take action. You make a phone call to the doctor’s office. “Hi, this is the pharmacy calling for Jane Doe. We sent a refill request for her lisinopril yesterday and wanted to make sure you received it.” This is your first escalation.
  • Clinical Urgency Triage: You don’t treat all pending requests equally. A pending request for a patient’s daily insulin is a much higher priority than a request for their seasonal allergy spray. You triage the queue based on clinical urgency and focus your follow-up efforts on the most critical medications first.
  • Problem Resolution: During the follow-up call, you might learn the doctor wants to see the patient before re-prescribing. You don’t just hang up. You close the loop. You call the patient. “Hi Mrs. Doe, I spoke with Dr. Smith’s office. He’d like to see you before refilling your lisinopril. Have you scheduled an appointment?”

This entire process—systematic review of a pending queue, a defined cadence for follow-up, triaging by clinical urgency, and proactive problem-solving—is the exact workflow of professional PA status management. You already have the skills and the mindset. You are now simply applying them to a different type of request with a different set of stakeholders.

8.4.2 Deconstructing the Status Code: A Translator’s Guide

The first step in effective follow-up is understanding what you are following up on. Digital PA platforms communicate the progress of a case through a series of status indicators. These can often be vague or ambiguous. A status of “Pending” can mean many different things. Is it waiting to be assigned? Is it actively being reviewed? Has it been forgotten? Your job is to translate these generic statuses into a precise operational meaning and a clear next action.

Masterclass Table: Translating Common PA Statuses into Actionable Intelligence
Status Indicator Literal Meaning Operational Translation (What’s Likely Happening) Your Next Action
New / Initiated A PA request has been created in the system. The process has started, but no one has done anything with it yet. It’s a placeholder. If pharmacy-initiated, confirm it was sent to the prescriber. If prescriber-initiated, this status is the starting point. No follow-up needed yet.
Sent to Prescriber (Pharmacy view on CMM) The PA request has been forwarded to the linked prescriber’s account. The ball is in the provider’s court. The payer has not seen this case yet. The clock on the payer’s turnaround time has not started. CRITICAL FOLLOW-UP POINT. If status remains for >24-48h, the provider’s office is the bottleneck. Call the provider, not the payer.
Submitted / Pending The request has been successfully submitted to the payer and is awaiting review. The case is in the payer’s work queue. It has been received but likely not yet opened by a human reviewer. This is the main “waiting” phase. Monitor according to your follow-up cadence. Note the submission date and time; this starts the clock on the payer’s required turnaround time.
In Review / Under Review A clinical reviewer at the payer has opened the case and is actively reviewing it. This is a positive sign of progress. It means your case has escaped the general queue and is being actively evaluated. Continue to monitor. Do not call at this stage, as it will interrupt the reviewer. A determination is likely imminent (within 24h).
Request for Information (RFI) / Additional Information Needed The reviewer needs more clinical data to make a decision. The PA has stalled. The payer has sent a request (via portal, fax, or phone) for specific documents, like chart notes or lab results. The review is paused until you respond. IMMEDIATE ACTION REQUIRED. This is your highest priority. Identify exactly what information is needed, obtain it from the provider, and submit it immediately via the requested channel.
Approved The payer has approved the medication. Success! The payer has generated an authorization number. Document the authorization number, start date, end date, and any quantity limits. Communicate the approval to the pharmacy and/or patient so the prescription can be filled. Close the case.
Denied The payer has denied the medication based on the information provided. The initial request failed. The payer must provide a specific reason for the denial and information on the appeals process. This triggers a new workflow. Analyze the denial reason. Was it a simple administrative error you can fix, or a clinical disagreement that requires a formal appeal or peer-to-peer review?

8.4.3 The Cadence of Follow-Up: Establishing a Proactive Rhythm

Effective follow-up is not random; it is systematic. You must develop a standard operational procedure (SOP) that defines the rhythm, or cadence, for how and when your team reviews and acts on pending cases. This cadence should be aggressive enough to prevent delays but reasonable enough to be manageable. It should also be informed by the urgency of the medication and any state or federal regulations governing payer response times.

Understanding Payer Turnaround Time (TAT) Mandates

You are not the only one working against a clock. Payers are often legally required to respond to PA requests within a certain timeframe. These TATs vary by state and type of request (urgent vs. standard).

  • Urgent Requests: For cases where a delay could seriously jeopardize the patient’s life, health, or ability to regain maximum function, payers are often required to provide a determination within 24 to 72 hours.
  • Standard Requests: For non-urgent cases, the timeframe is typically longer, often ranging from 5 to 14 calendar days.

As a CPAP, you must be aware of the specific regulations in your state. Knowing that a payer has a 72-hour mandate for an urgent request gives you incredible leverage. If you haven’t received a response by the 48-hour mark, your follow-up call is not just a request; it’s a compliance check-in.

A Standard Follow-Up Cadence Workflow

The following represents a best-practice model for a follow-up workflow. This should be the default procedure for all standard PA cases, which can be accelerated for clinically urgent requests.

T=0

Day 0: Submission

The PA is successfully submitted to the payer via the chosen platform (ePA, Portal, Fax). The communication log is updated with the submission confirmation and reference number. The “TAT clock” has started.

T+1

Day 1: Initial Status Check (The “Triage” Follow-Up)

Action: Check the status on the relevant platform.
Goal: Ensure the PA wasn’t immediately rejected for a simple administrative error (e.g., incorrect member ID, missing NPI). If a “Request for Information” (RFI) status appears, this is your chance to catch it early and act immediately.
Outcome: If status is “Pending” or “In Review,” no further action is needed. If it’s an RFI, begin the information gathering process.

T+3

Day 3: The First Proactive Contact (The “Nudge” Follow-Up)

Action: If the status is still “Pending” with no change, make the first proactive follow-up call to the payer.
Goal: Verbally confirm receipt of the PA and all supporting documents. Ask if the case has been assigned to a reviewer and if there is an estimated timeframe for review.
Outcome: This call serves two purposes: it confirms your case is not lost in the system and gently “nudges” it, sometimes prompting it to be assigned. Document the call, representative’s name, and reference number.

T+5

Day 5: The Escalation Point

Action: If the case is still pending and has breached the payer’s standard or regulated TAT for a determination, it is time to escalate.
Goal: Get the case out of the standard queue and into the hands of someone with the authority to resolve it.
Outcome: This triggers the Escalation Playbook (see next section). Your call is no longer a simple status check; it is a request for direct intervention.

8.4.4 The Escalation Playbook: When the System Fails

Sometimes, despite your diligent follow-up, a case will become truly stalled. The provider’s office may be unresponsive, or the payer’s internal process may have failed. In these moments, you must shift from a case monitor to a case advocate. Escalation is a formal process of raising the visibility and priority of a stalled case. It should be used judiciously but decisively.

Triggers for Escalation
  • Time-Based Trigger: The case has aged beyond the established follow-up cadence (e.g., >5 business days) or has exceeded the legally mandated TAT.
  • Clinical Urgency Trigger: The patient’s clinical condition has worsened, or they are at immediate risk of harm due to the delay (e.g., an inpatient whose discharge is being held pending PA).
  • Process Failure Trigger: You have identified a clear process failure, such as a lost fax, a non-responsive provider, or conflicting information from multiple payer representatives.
The Pharmacist’s Escalation Script

When you call to escalate a case, your tone and language must shift. You are no longer asking, you are asserting. This script is designed to be professional, firm, and effective.

“Hello, my name is [Your Name], and I am a clinical pharmacist calling on behalf of [Patient Name]. I am calling to escalate the prior authorization for [Drug Name], case reference number [Case #]. This request was submitted on [Date of Submission], which is now [X] business days ago. The standard turnaround time for this request is [Y] days, and we have not yet received a determination. The delay is now impacting patient care, and I need to speak with a supervisor or a lead clinical reviewer to get this case resolved today.”

Key elements of this script:

  • It immediately identifies you as a clinical professional.
  • It frames the call as an “escalation,” using formal language.
  • It provides all the key data points (case number, submission date) upfront.
  • It explicitly states that the payer is outside its own service level agreement or regulated TAT.
  • It links the delay to patient care, raising the clinical stakes.
  • It makes a direct, non-negotiable request to speak with a decision-maker.