MCCCD Program Description

Prescription Prior Authorization II

Course: CSR146

First Term: 2025 Spring

Lec + Lab 4.0 Credit(s) 4.0 Period(s) 4.0 Load
Subject Type: Occupational
Load Formula: T - Lab Load

Description: Advanced prescription prior authorization procedures for federal employees. Usage of various computerized databases emphasized. Includes drug benefit management, drug limitation guidelines, standard allowance fill quantity, and prior authorization fill quantity. Approved and denied authorizations also covered in addition to grandfathered records and change in therapy procedures.

MCCCD Official Course Competencies
1. Use various databases. (I-VII) 2. Manage Federal Employee Program (FEP) drug benefits. (II) 3. Use FEP drug limitation guidelines. (III) 4. Process medications requiring authorizations. (III) 5. Differentiate between prior authorizations, approved authorizations, and denied authorizations. (IV-VI) 6. Explain the importance of authorization begin and end dates. (IV-VI) 7. Verify whether the provided diagnosis meets clinical criteria. (IV-VI) 8. Collect Prior Authorization number (PA) information. (IV) 9. Demonstrate ability to ask drug protocol questions. (IV) 10. Complete grandfathered record procedures. (IV) 11. Differentiate between standard allowance and prior authorization fill quantities. (VII) 12. Verify authorized quantities have been filled. (VII) 13. Complete change in therapy procedures. (VII)
MCCCD Official Course Competencies must be coordinated with the content outline so that each major point in the outline serves one or more competencies. MCCCD faculty retains authority in determining the pedagogical approach, methodology, content sequencing, and assessment metrics for student work. Please see individual course syllabi for additional information, including specific course requirements.

MCCCD Official Course Outline
I. Computerized databases A. Logon B. Menus C. Codes D. Screens E. Logoff II. Drug benefit management A. Overview B. Patient/cardholder information C. Account history D. Authorizations E. Adding records F. Approvals G. Denials III. Drug limitation authorization A. Overview B. Patient/cardholder information 1. Existing account 2. New account C. Drug identification D. Approvals IV. Prior authorizations A. Overview B. Prior authorization information 1. Caller`s name 2. Caller`s title 3. Doctor`s name 4. Doctor`s specialty 5. Doctor`s National Provider Identifier (NPI) number 6. Phone/fax numbers 7. Doctor`s address, drug 8. Strength of drug 9. Quantity of drug C. Member eligibility verification 1. Protected Health Information (PHI) 2. Member`s insurance identification 3. Member`s name 4. Member`s date of birth 5. Member`s address D. Select drug E. Drug classification F. Drug protocol questions G. Diagnosis verification H. Prior authorization dates 1. Research 2. Locations I. Grandfathered records V. Approval authorizations A. Overview B. Patient/cardholder C. Verification of drug D. Authorization by E. Begin/end dates VI. Denied authorizations A. Patient/cardholder eligibility B. Drug selection C. Drug classification D. Drug protocol questions E. Diagnosis verification F. Clinical rationale G. Denied status dates H. Previous denial dates I. Authorization/denial by J. Begin/end dates VII. Verification of filled prescriptions A. Overview B. Rx number C. Standard allowance fill quantity D. Prior authorization fill quantity E. Rejection of authorized medication F. Verification of authorized quantity at pharmacy 1. Mail order pharmacy 2. Retail pharmacy G. Drug classifications H. Change in therapy 1. Types 2. Procedures

MCCCD Governing Board Approval Date: November 26, 2024

All information published is subject to change without notice. Every effort has been made to ensure the accuracy of information presented, but based on the dynamic nature of the curricular process, course and program information is subject to change in order to reflect the most current information available.