Important Data Caveat & System Disclaimers

Data Warehouse Notice: Due to ongoing data warehouse migrations, architecture modifications, and platform limitations, certain historical or recent data elements may be incomplete or subject to processing lags. Volume totals and metrics should be treated as provisional and representative of data available at the time of the dashboard refresh.

Data Exclusions & Definitions

• Note on Exclusions: There are 13,070 prior authorization requests that do not fall into expedited, extended, or standard requests. These were generally longer than 14 days without an associated extension. These were excluded from data on standard and expedited requests, as well as their related time graphs. These prior authorizations were put into their own grouping called ‘delayed’.

Prior Authorization Decision Timeframes

The operational baselines for processing timelines are defined as follows:

• Expedited (Urgent) Requests: Decisions must be rendered within 72 hours.
• Standard (Non-Urgent) Requests: Decisions must be rendered within 7 calendar days.
  • Extension Clause: Standard requests may be extended up to 14 calendar days if the provider requests an extension, or if the prior authorization team determines that additional information from the provider is needed to make an informed decision.

Methodology: PA Volume by Provider Chart

To ensure high data integrity and capture true corporate facility trends, the Monthly Prior Authorization Volume by Provider chart operates under the following logic:

• Data Mapping via PRISM Claims: Rather than using raw, unverified data entry fields from the initial PA request screen (which often contain individual clerk names or typos), the dashboard dynamically links each PA to its corresponding medical claim header in PRISM. It pulls the verified Billing Provider Organization Name associated with the first Transaction Control Number (TCN).
• The “Top 10 vs. Other” Consolidation: To keep the visualization clean and scannable, the dashboard evaluates total volume across the year and isolates the top 10 highest-volume billing systems. All remaining independent clinics, low-volume providers, and specialized groups are aggregated into a single baseline category labeled ‘Other’.
• Handling Denied and Unbilled PAs: If a PA request is denied, or if it is approved but a claim has not yet been processed against it, no TCN record will exist in the claims system. To prevent these records from being lost, the data pipeline uses a safety fallback that groups these unmatched requests into a category labeled ‘No Associated Claim’. This ensures that the total volume of this chart matches your main volume charts exactly.