Managing Authorizations: Status Options & Descriptions

Sending

The authorization is being sent to the payer. 

If the authorization remains in Sending status for an extended period, report it to our Customer Operations team by emailing help@samacare.com or using the chat widget.

Pending

The authorization has been received and is currently under review. 

Approved

The authorization has been approved by the payer exactly as submitted.

When updating the authorization to Approved, be sure to update the authorization number and dates of service.

Modified Approval

Denied

The authorization has been denied by the payer.

• Dosing/frequency criteria not met
  • The requested dosing or frequency does not meet the payer policy criteria.
• Step therapy requirements not met
  • Required prerequisite therapies were not attempted, or documentation was not provided to show completion of step therapy requirements.
• Payer policy denial
  • The request was denied based on the payer’s clinical or coverage policy.
• Drug excluded under medical benefit
  • The requested drug is not covered under the patient’s medical benefit.
• Provider is out of network
  • The rendering provider is not contracted with the payer.
• Not medically necessary
  • The payer determined that the request does not meet medical necessity criteria.
• Must go through the pharmacy benefit
  • The request must be processed under the patient's pharmacy benefit.
• Must go through the medical benefit
  • The request must be processed under the patient's medical benefit.
• Other

  • Use this option when no predefined denial reason applies.

Action Required

Additional action is required before a determination can be made.

• Additional information requested.

  • The payer has requested missing information, clinical documentation, or other supporting materials.

• Patient not found

  • The payer is unable to locate the patient in their system using the information provided in the authorization.

• Cannot backdate
  • The payer does not allow retroactive authorizations.
• Wrong form
  • The authorization was submitted using the incorrect form.
• Routing/department issue

  • The authorization was sent to the wrong department, plan, or payer.

• Member not eligible/coverage lapsed
  • The member's coverage is inactive or expired.
• Must go through the pharmacy benefit

  • The request needs to be submitted through the pharmacy benefit. Some payers use this as an action-required reason rather than a denial.

• Must go through the medical benefit

  • The request needs to be submitted through the medical benefit. Some payers use this as an action-required reason rather than a denial.

• Existing Auth on File

  • There is already an authorization on file for the same drug and dosage, with service dates that overlap the requested authorization.

• Other

  • Use this option when no predefined reason applies.

Appeal Pending

Duplicate

No Authorization Required

Voided