The Patient Chart

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When you open a patient record you see three areas: the header (patient demographics and summary cards), the sidebar navigation (section links), and the main content panel (the selected section’s data).

To review a patient’s prior authorization status, open the Overview tab. It is the patient’s prior authorization story: every PA episode for the patient, open and closed, grouped by medication and then by episode. Open episodes surface the current PA state, data-request prompts, and action items; closed episodes — including completed denials — stay in the list so you can see what was already decided.

When you arrive from the task queue with an open task selected, Overview opens focused on that task and a Complete Task button appears near the top of Overview (labeled Mark Reviewed for document-review tasks). Select it to mark that task complete and refresh the timeline. The button does not appear when you open Overview without a focused task. A closed prior authorization or continuation opens on Overview with that episode expanded. Closed therapy interchange, legacy therapy discontinuation, and child workflow tasks open on Tasks with their history expanded.

The Patient Header

The header at the top of the chart is arranged in three columns: the patient summary on the left, and the Notes and Alerts and Care Team cards to its right.

The patient summary always shows:

  • Patient name — the patient’s full name, with a pencil icon to edit demographics.
  • Cardholder ID — the active insurance member/cardholder ID when the chart has one. When a person code is on file, the chart shows it separated from the member number by |. Select the copy icon beside Cardholder ID to place the member number and person code together on your clipboard, without the separator shown on the chart.
  • DOB — date of birth.
  • Groups — a chip for each business unit this patient belongs to. If no business unit is assigned, an Assign Business Unit button appears instead.
  • Schedule a review — a button below the summary. Select it to put a future prior authorization review on the calendar for this patient. See Scheduled Reviews.

Below the summary is a Show contact details toggle. Select it to expand the patient’s contact information; the button changes to Hide contact details so you can collapse it again. When expanded, it reveals:

  • Address — street, city, state, and ZIP.
  • Phone — the preferred phone number and type. The number is a clickable link that opens your device’s dialer, and an SMS OK badge appears if the patient can receive text messages.
  • Email — the contact email as a clickable link that opens a new message in your mail app, with an Email OK badge if email communications are enabled.

The header also contains two summary cards beside the patient summary:

Notes and Alerts Card

Displays active alert chips (color-coded by severity) and recent notes attached to this patient. Select the pencil icon to add or edit notes and alerts.

Care Team Card

Lists the patient’s assigned prescribers and providers, including their specialty and location. Select the pencil icon on the patient name to update care team members through the edit panel.

The left sidebar under Patient Chart links to the core clinical data sections:

Overview

The default landing section. Shows the patient’s clinical workflows at a glance — prior authorization episodes both in progress and already decided, therapy interchange conversions, legacy therapy discontinuation reviews, other patient tasks, rejected claims that still need evaluation, and recent guideline evaluation results. Use this section to see what is pending and what has already been determined without digging through individual task records. The Tasks tab remains the patient’s full root-task history.

When a patient has more than one kind of workflow, a pill group appears at the top of the Overview with a pill for each one the patient actually has: Prior Authorization, Therapy Interchange, and Legacy Therapy Discontinuation. Select a pill to switch between the workflow timelines. When only one type of workflow exists, the pill switcher is hidden and that workflow’s section shows automatically.

Prior Authorization section: presents a single Medication chip selector that lists every drug with a prior authorization episode — open or closed — plus any drug whose rejected claim has no episode yet. When only one medication qualifies, the selector is hidden and that medication shows automatically. Prior authorization episodes whose medication was never recorded are gathered under one Unknown Medication chip at the end of the list, so those episodes are still there to read.

Every chip names its drug the same way: the ingredient, plus the brand when the claim or the prior authorization identifies one — for example Semaglutide (Brand: Ozempic) or Adalimumab (Brand: Hyrimoz). A drug dispensed as a generic reads Atorvastatin (Generic), and a drug with no brand information at all reads as the ingredient alone. A chip reads identically whether the drug’s only evidence is a pharmacy rejection or it already has prior authorization episodes, and it matches the medication named on that drug’s episode rows below, so you can follow one drug across the whole screen. A red dot on a chip marks a rejected claim that no episode covers yet.

Selecting a medication lists that drug’s PA episodes beneath the selector, newest first, with one row per prior authorization. Each row header shows the task type, the medication the episode is for (for example Semaglutide (Brand: Wegovy)), a GoldCard badge when the PA came from a GoldCard configuration, its workflow state (for example Denied, Approved, Abandoned, or a pending data request), the full created date and time in UTC, the assignee’s name, and the assignment group when one is set (shown as — when no group is assigned). An episode with no medication recorded simply shows no medication chip, and an episode with no assignee shows Unassigned. Open episodes are expanded for you; a closed episode stays collapsed unless it is the one you arrived at from the task queue or the one that covers this drug’s latest rejected claim.

When you arrive from the task queue with an open task in focus, Assign appears beside Complete Task at the top of the Overview. Assign opens the same assignment dialog used on the task queue: set a person, an assignment group, or both, and clear either field to return work to the group pool or leave it unowned. Closed or otherwise non-open tasks do not show Assign.

Expand a row to load that episode’s workflow timeline in place — the same timeline you see on the task itself, listing current state, data requests, determination letters, PharmPix entries, and links to communications, newest first with the current action at the top. Timelines load as you expand them, so a patient with a long PA history opens quickly. Each timeline event shows the date and time together with who performed the action — a user’s name when someone manually approved, reviewed, or transitioned the workflow, or system when the application performed the step automatically. When a PA was started from a GoldCard schedule, a GoldCard chip appears in the timeline header alongside the medication and state chips.

Next-step actions apply to the open episode you are focused on. A closed episode is there to be read; the re-evaluation and appeal actions on its own timeline remain the way to reopen it.

A drug whose latest rejected claim has no matching episode — never evaluated, or the previous PA was abandoned and no new one has started — shows a Next Step: Start Evaluation action instead of an episode timeline. The reject banner and the Evaluate button name the drug exactly as its chip does, so you can confirm which medication you are about to evaluate. If task history is temporarily unavailable, the chart withholds this action until it can confirm that no active episode already exists.

When a completed evaluation marks an exact rejected claim as covered by the standing denial, Overview does not offer Start Evaluation for that claim. The closed denial listed under that drug is the answer — expand it to read the determination, the letters, and the pharmacy retries that followed. If current guideline review finds that new information is needed or the determination may change, that same PA reopens with its original timeline and the next action rather than starting a separate one. After an approval, a later rejected claim can begin a new PA and show Start Evaluation.

When a PA closes because the patient’s coverage ended, its row shows a Termed state with Coverage ended wording and a link to the full task timeline.

When a completed guideline evaluation says Not evaluated, the result explains why the clinical rules were not run. If the guideline’s Matching Rules excluded it, the timeline states why — for example the prescriber’s taxonomy did not match, or the medication’s route or dosage form did not match (such as an injectable claim when the guideline is limited to oral tablet). A matching-rules skip does not open a data request. Select View Details to confirm the evaluation type, current-therapy status, and that the rules were skipped.

When a determination is available, the timeline shows Determination Review with a Review button that expands the review panel. If your tenant has Determination LLM summary turned on, a plain-language summary banner also appears above those controls; when the summary is off, you still use the same review experience without that text. There you can read the clinical criteria tree (each requirement marked with a green check and Criteria met or a red X and Criteria not met; when a guideline uses an ontology rule, the rule appears as its own row that names it, states whether the patient must match or must not match it, and shows one result for the whole rule, with the diagnosis, drug, or procedure checks it ran listed beneath as supporting detail; long ontology diagnosis lists start collapsed with Show N diagnoses, and a group or ontology with six or more requirements starts collapsed with Show N requirements under its row, which stays visible with its result), preview the patient’s documents inline — scroll continuously through a multi-page PDF, open plain-text files in place, or use the PDF toolbar search field (magnifying-glass icon) to jump between text matches — upload a new document via the + next to Documents, and use Enter Missing Clinical Data under Chart Updates. The chart-entry form opens in a panel on the right side of the screen so the document preview stays visible. Each failed requirement shows Current versus Required; when several ICD codes apply, choose one code, set its status and date, then select Add entry to record another. Each requirement also asks Was this fact present in the document you reviewed? — answer Yes (after selecting the document) to record the fact as coming from that document, or No to record it as a chart entry of your own. Supported updates save directly to the patient chart without re-evaluating. Select Pause or Complete to collapse the panel. After you complete a review, if the chart is updated or a new evaluation runs, Review again appears so you can reopen the panel. This is the same Determination Review experience available on the PA task detail page.

When a determination is rejected, the timeline’s Next Steps: Determination Rejected card lets you Enter Missing Clinical Data without leaving the workflow — the same chart-entry panel opens on the right side of the screen, and the document preview stays visible. If an entry that must be stored with the document cannot be written, the form shows an error and does not confirm the save. Re-evaluation stays a separate, explicit Re-evaluate Against Guidelines step — including when a banner notes that chart data has changed since the determination. The card confirms Re-evaluation started. while it runs and Re-evaluation completed. once it finishes.

After a denial is sent, the timeline may show a red PharmPix Denial entry noting that the denial was recorded with the pharmacy benefit system. It is distinct from the red Rejection entry, which is the clinical determination itself, and neither entry means the medication was approved.

If PharmPix reports that a member has no active insurance, the other insurance on the chart that covers today is tried automatically. When every current member is rejected, the timeline shows one PharmPix: No Active Insurance entry naming those members, and a Next Step: Review Insurance & Retry PharmPix card names them too. When that failure belongs to the task awaiting approval, this card is the only next step shown for it. Review the insurance on the chart, correct it if needed, then select Review & Retry PharmPix. For any other PharmPix error, the card reads Next Step: Retry PharmPix Submission.

When a PA is awaiting data, the timeline shows a Next Steps: Resolve Data Request card. Once the requested clinical data is present on the chart, the data request is fulfilled and the PA is re-evaluated automatically. Select Re-evaluate now in that card to trigger re-evaluation immediately.

Therapy Interchange section: shows the full interchange workflow timeline for each drug, in the same chronological format as the PA timeline. Events appear in order:

  1. Workflow Created — when the therapy interchange task was initiated.
  2. TI Rules Evaluation — the evaluation run and its result.
  3. Therapeutic Interchange Data Request — when missing clinical data was requested (prescriber fax, with requested items listed). When this request is still open, the same Next Steps: Resolve Data Request card appears so you can fax the prescriber, upload a document, manually enter the data, or select Re-evaluate now after updating the chart.
  4. Source Authorization Queued — when the member met the rules and the source authorization was accepted for processing.
  5. Move to Preferred Drug — when the member failed the interchange rules, or the requested clinical information expired.
  6. Move-to-Target Letters — a grouped card showing the required prescriber notice and optional patient and pharmacy notices.
  7. 30-Day Refill Block Queued — when the automated PharmPix refill block was accepted for processing. Rules failures and expired data requests have distinct timeline wording.

Older historical episodes may still show Conversion Letters and Source Authorization Ended because they used the former teardown process. New failures do not use that event.

When multiple interchange medications exist, a drug chip selector appears above the timeline so you can switch between them. A View Full Task Details button opens the interchange task record.

Legacy Therapy Discontinuation section: shows the same chronological timeline for each legacy therapy under review, with wording that reflects ending the therapy rather than substituting another drug. Events appear in order:

  1. Legacy Therapy Review Started — when the discontinuation review was opened for this drug.
  2. Discontinuation Rules Evaluation — the evaluation run and its result.
  3. Legacy Therapy Data Request Fax — when missing clinical data was requested from the prescriber, with the requested items listed. While this request is open, the same Next Steps: Resolve Data Request card appears so you can fax the prescriber, upload a document, manually enter the data, or select Re-evaluate now after updating the chart.
  4. Source Authorization Queued — when the member met the criteria, stays on the therapy, and the source authorization was accepted for processing.
  5. Discontinue Therapy — when the member failed the criteria, or the requested clinical information expired.
  6. Therapy Discontinuation Letter — a grouped card showing the required prescriber notice and the optional patient and pharmacy notices. No replacement medication is named.
  7. 30-Day Refill Block Queued — when the automated PharmPix refill block was accepted for processing.

This section has its own medication chip selector and its own View Full Task Details button; discontinuation episodes are never listed together with interchange episodes.

Other Tasks: patient-linked root tasks that do not belong to the medication-based PA, interchange, or legacy therapy discontinuation sections appear beneath those workflows. This includes documents that need review. Each row uses the same task type, optional medication, status, UTC creation time, assignee, and assignment group details as a PA episode, and expands to show its available timeline.

Selecting View Evaluation from within the timeline switches you directly to this patient’s Evaluations section with the relevant evaluation detail panel open — you stay within the patient chart rather than navigating to the population-level evaluations list.

When a patient has no open PA workflows, no interchange or legacy therapy discontinuation workflows, no other root tasks, and no rejected claims requiring review, the Overview shows an All Clear indicator confirming no workflow action is needed. A closed PA episode can still be listed for a drug alongside All Clear, and a rejected claim already covered by a completed denial does not prevent it. When an Other Tasks section is present, All Clear is hidden.

Medications

Lists the patient’s current and historical medications from claims and confirmations. By default you see active fills — paid claims that are still in effect. Show rejected claims reveals pharmacy rejections when you need to investigate them. Show reversed claims reveals voided originals and their matching reversal transactions (offsetting rows with negative cost). Leave both toggles off for the everyday view; turn them on when you need the full claim history behind a medication.

Brand products appear as Brand (generic) — for example, Zepbound (tirzepatide) — while true generics show only the generic ingredient name. Each card shows status and type chips, fill timeline, brands, and therapeutic class codes when available.

Expand Show Claims on a card to review claim rows that mirror the Claims display (submission date, fill date, ingredients, brand, NDC, source, status, and quantity), plus days supply, times refilled, and strength. Rejection codes are not listed in the table — open a rejected claim to see them in the details panel. When reversed claims are visible, status distinguishes reversed (the original fill that was voided) from reversal (the offsetting transaction). Click a claim row to open the medication claim details panel.

Some medications are recorded from a document — a fax or progress note stating the patient is taking the drug — rather than from a pharmacy claim. Those entries have no dispensing detail behind them, so the NDC column shows an em dash (—) instead of a code. Open the claim and the Medication Claim Details panel tells you why: the NDC reads NDC not available, imported from document, and the pharmacy and prescriber show as Unknown pharmacy and Unknown prescriber with no identifier beside them. Because there is no prescription behind these entries, the panel leaves out the RX Number row rather than showing an internal reference.

Instead, the panel shows a Source Document section for those claims with the document’s filename, type, and the date it was received, plus a Download / View button that opens the original fax or note in a new tab — the same control you get on a medication confirmation. If the document can no longer be retrieved, the section says the source document is not available. Claims that came from a real pharmacy fill continue to show the NDC, the RX number, the pharmacy and prescriber names, and their NPI numbers as before, and have no Source Document section. When you open a rejected claim, the Medication Claim Details panel lists every rejection code under Basic Information (paid claims with no codes omit that row).

On each active medication card you see a Medication Possession Ratio (MPR) percentage. MPR shows how consistently the patient has kept that medication filled over the past 12 months, or since therapy began if that is shorter. Reversed or cancelled fills do not count toward the ratio. The value can exceed 100% when refill coverage periods overlap.

Diagnoses

Lists diagnosis codes (ICD codes) on file for this patient, along with dates and source information.

Procedures

Lists procedure codes (CPT/HCPCS) associated with this patient.

Observations

Displays clinical observations recorded for this patient. Results are grouped by LOINC category — Laboratory, Clinical, Surveys & Questionnaires, and Claims Attachments. Those groups appear as tabs at the top of the section, each with a count, so you can switch between them without scrolling a stacked list. Empty tabs stay visible and appear quieter than ones with data. When results first appear, the first tab that has data is selected unless you have already chosen a different tab. Use Filter tests at the top of the section to narrow the list by test name or LOINC code. Within the Laboratory tab, results are further divided by panel type when more than one panel is present: Chemistry, Hematology, Microbiology, Serology, and Toxicology. If every lab result belongs to a single panel, that extra heading is omitted so you do not see the same count twice. Each individual test also starts closed; open it to see its result table. Dates are collection dates — a time of day appears only when one was recorded. Lab values relevant to prior authorization criteria appear here alongside other recorded clinical data.

When the same result appears in more than one document — for example, the same lab value reported on multiple faxes — you see one row, not a duplicate for each document. The Source column shows where that result came from and how many documents reported it; when several documents share the same source type, the label includes a count (for example, Fax/Upload ×3). Select a row to open its details panel. If the result came from multiple documents, the panel notes Reported in N documents and lists each document once, with its own Download / View link — a document that reported the same result several times still appears as a single card, noting how many entries it contributed. Edit and Delete on that row apply to all underlying entries behind it — if you remove a merged row, every duplicate stored from those documents is removed together. If a delete only partly succeeds, you are told how many entries were removed and the panel narrows to the entries that are still stored, so selecting Delete again retries just those.

Select Add Observation to record a new result — enter a LOINC code, date, value, and unit. After you save, the matching category tab opens and the new test is expanded so you can see the result. There is no source picker; observations you add from the chart are saved with Chart as the source.

Insurance

Lists each insurance coverage on file as its own card. The title on each card is the carrier name from your organization’s business units — the same names you maintain in Business Units administration — matched from the coverage record. When no carrier can be identified from your business units, the card shows the carrier recorded on the coverage itself, and reads Unknown Carrier when none was recorded.

Each card shows:

  • Payer ID — the carrier recorded on the coverage; blank when none was recorded.
  • Group ID
  • Cardholder ID
  • Subscriber
  • Relationship
  • Coverage Start
  • Coverage End

Open coverage is listed first. Coverage that has already ended is listed below it, on a light grey card with an Expired badge beside the carrier name. A coverage with no end date stays with the open cards.

Prior Authorizations

Lists all prior authorization records for this patient, grouped by medication. Each record shows a status chip — Approved (active PA on file), Ended (PA was approved but has since been revoked or has expired), Rejected (clinical denial on file), or Pending (no determination yet). An Ended authorization means the PA was once approved and has been closed out in PharmPix or reached its end date; it does not indicate a clinical denial and will not trigger a new prior-authorization episode.

Below the Patient Chart group, the sidebar lists additional sections:

Tasks

The patient’s root-task history, newest first: prior authorization, PA continuation, therapy interchange, legacy therapy discontinuation, and document-review tasks. GoldCard work appears as a prior authorization with a GoldCard badge; it is not a separate task type. Unmatched documents are not listed because they have not been linked to a patient.

Each row shows the task type, the medication the task is for (for example Semaglutide (Brand: Wegovy); tasks with no medication recorded show no medication chip), the optional GoldCard badge, status (or workflow stage), the full created date and time in UTC, assignee (the person’s display name, or Unassigned when no one owns the task), and assignment group (— when none is set). Open tasks include an Assign button on the row so you can set or change the owner and group without leaving the chart; completed and other closed tasks stay read-only. Select a row to expand it and load that task’s workflow timeline in place — child tasks and events appear inside the expanded timeline, not as separate top-level rows. Select the row again to collapse it. If older history exists beyond the first page, select Load More at the bottom of the list.

When you open a closed therapy interchange, legacy therapy discontinuation, or child workflow task from the task queue, this tab opens with its root history expanded and scrolled into view. If the root lives further down the history, the list loads additional pages automatically until it finds and reveals the matching row. Closed prior authorization and continuation roots open on Overview with their medication episode expanded.

Use Tasks when you want the complete record of everything raised for this patient, including tasks that are not prior authorization episodes. Use Overview when you want the clinical picture for one drug — its PA episodes in order, open and closed, with the next action on the open one.

Evaluations

A history of guideline evaluations run against this patient. Each row shows the date, guideline, type, status, current therapy, outcome, and how many tasks were created.

For standard prior-authorization evaluations, Type is Initiation or Continuation, PA Status shows Approved (or a rejection date), Current Therapy is Yes or No, and Outcome uses PA wording such as Prior Auth or Data Request.

For Therapeutic Interchange evaluations, the same columns use interchange wording instead of PA vocabulary: Type shows Therapeutic Interchange, PA Status is blank (an em dash), Current Therapy shows On Source Drug when the member is on the source drug, and Outcome shows Source Authorization Queued, Source Authorization Pending, Move to Preferred — 30-Day Refill Block Queued, Data Request Expired — 30-Day Refill Block Queued, Clinical Information Requested, or an explicit historical label for older records. Mixed PA and interchange history can appear in the same table.

For Legacy Therapy Discontinuation evaluations, Type shows Legacy Therapy Discontinuation, PA Status is blank (an em dash), Current Therapy shows On Source Drug, and Outcome shows Continue Therapy, Continue Therapy — Source Authorization Queued, Continue Therapy — Source Authorization Pending, Clinical Information Requested, Discontinue Therapy — 30-Day Refill Block Queued, or Data Request Expired — 30-Day Refill Block Queued. No outcome on these rows refers to a preferred or target drug.

Select any row to open the Evaluation Audit panel — a letter-like, read-only record of exactly why that evaluation reached its result. The audit outcome chip uses the same labels as the Evaluations list for whichever program produced the row.

  • Header — the evaluation date, a type badge (Initiation, Continuation, Therapeutic Interchange, or Legacy Therapy Discontinuation), and an outcome chip.
  • Skipped evaluations — when no criteria were run, an information banner explains why the guideline was skipped and names the affected phase. The panel does not show an outcome or approximate criteria for a skipped evaluation.
  • Guideline — the guideline name and the version of the guideline that was in effect at evaluation time.
  • Notices — a banner if the historical patient chart could not be recovered for this evaluation, a footnote if criteria statuses are approximated rather than exact, and an explanatory note when a source-therapy evaluation has no criteria to display. For an interchange that note describes staying on the source drug, moving to the preferred drug, or needing a data request; for a legacy therapy discontinuation it describes staying on the therapy, discontinuing it, or needing a data request.
  • Value Changes Since Last Evaluation — when a value referenced by the guideline (for example a lab result) differs from the same patient’s prior evaluation against this guideline, it’s called out here as a “changed from X to Y” line.
  • Criteria — the full requirement tree as it was evaluated, with each requirement or group marked Met (green), Not Met (red), or Data Needed (orange). An ontology rule appears as its own group that names the rule and states whether the patient must match or must not match it; its status is the result for the whole rule, and the checks it ran are listed beneath it. Long diagnosis lists and long requirement lists under a group start collapsed the same way as on Determination Review (Show N diagnoses, Show N requirements); expand to see every line.
  • Links — View Evaluation Run Details and View All Patients in Run open the population-level evaluation record.

Documents

Documents uploaded or received for this patient — prior auth letters, clinical notes, and other attachments. You can upload new documents and view or download existing ones from this section. Pending inbox documents can be deleted from this list; GEMA asks you to confirm in a dialog first, and shows an in-app error notification if the delete fails.

When your organization’s monthly AI budget is being paced, a document shows Waiting for AI budget with a clock icon. This is not an error. The document is picked up automatically when budget becomes available, and Retry extraction is not offered while it waits.

Correspondence

Outbound letters and fax records associated with this patient — determination letters, denial notices, data-request letters (including Excluded Brand Data Request, GoldCard Data Request when outreach came from a GoldCard schedule, Therapy Interchange Data Request when a therapeutic interchange review needs more clinical information, and Legacy Therapy Discontinuation Data Request when a legacy therapy review needs more clinical information), GoldCard Initiation and GoldCard Rejection notices for proactive GoldCard reviews, Therapy Interchange Move to Preferred notices, Legacy Therapy Discontinuation notices, and other communications sent via the system.