Status Options & Descriptions

• Sending
• Sent to Payer
• Pending 
• Approved
• Modified Approval
• Action Required
• Denied
• Appeal Pending
• Duplicate
• Voided
• No authorization required

This article is crafted to illuminate the various statuses within SamaCare, offering a profound understanding of their significance and, if applicable, providing guidance on the subsequent steps to navigate each status.

Sending

• The prior authorization request is being sent to the payer.
  • If the authorization remains in "Sending" status for an extended duration, please report it to our Customer Operations team via email at help@samacare.com or through the chat widget. 

Sent to Payer

• We received confirmation that the prior authorization request has been sent to the payer.

Pending 

• The prior authorization request is pending review by the payer.

Approved

• The prior authorization request has been successfully approved by the payer. This confirmation was obtained because we received a communication directly from the payer or via confirmation from the payer during a check-up call.
  • Once a communication is received we will ensure it is attached to your request promptly.

Modified Approval

• This prior authorization request has been approved with conditions. 
  • Please take a moment to review the attached response to view the conditions of this approval. This will provide you with detailed insight into the terms and requirements associated with the approval. 

Action Required

• The prior authorization request requires additional information from the practice to facilitate its processing.
  • Contact the payer - Please reach out to the payer using the contact number provided on the response to proceed with this authorization request.
  • General questions - The payer has requested that questions be answered and submitted before proceeding with this request.
  • Printable form - The payer has requested that a printable form be completed and submitted prior to processing the request.
  • Edit and resubmit - An edit needs to be made to your request and it needs to be resubmitted for processing.
  • Resubmit - Your request needs to be resubmitted. The reason for this may or may not be specified.
  • Missing form - A required form or document is missing.
  • Patient Not Found - The patient in the request is not found by the payer.
  • Cannot Backdate - This request cannot be backdated.
  • Wrong Form - The wrong form was used in this request. 
  • Missing Information(not error) - The request is missing required information.
  • Wrong Location/Number - This request was faxed to the wrong location or number.
  • Carve Out/Dedicated Department - There is a dedicated department for this request
  • Member not Eligible/Coverage Lapsed - The member is not eligible for this medication or the members coverage lapsed.
  • Must Go Through Pharmacy Benefit - This request must be submitted through the Pharmacy Benefit.
  • Must Go Through Medical Benefit - This request must be submitted through the Medical Benefit.
  • Existing Authorization on File - There is an existing authorization on file for this request. 
  • Other - Additional information will be provided explaining the information we received on the response. 

Denied

• The prior authorization request has been denied by the payer.
  • Dosing/Frequency Not Met - The response states denied due to dosing/frequency limits requested.
  • Step Therapy Requirements Not Met - The response states denied due to step therapy requirements not met.
  • Clinical Criteria Not Met - The response is denied due to certain criteria not met that is not one of the options listed above.
  • Payer Policy Denial - The response states denied due to a payer policy. 
  • Drug Excluded Under Benefit Plan - The response states denied due to the drug not being covered under the patients benefit plan. 
  • Provider is Out of Network - The response states denied due to the provider being out of network. 

Appeal Pending

• The prior authorization request was denied and an appeal has been filed.
  • While SamaCare does not currently support the appeal process, we provide this status to enable you to track and manage your Prior Authorization efficiently through our platform. This feature ensures that you can stay informed about the progress of your Prior Authorization, facilitating effective management and oversight.

Duplicate

• The prior authorization request is a duplicate request.

Voided

• The prior authorization request has been canceled or voided.

No authorization required

• The request does not require prior authorization. 

If this is a step by step process with multiple articles associated add the following below:

Guide me to "Summary Details - Events (Status Descriptions)"

We're here to guide you through your prior authorization quest!