The PA Workflow
When you open a prior authorization (PA) or Therapy Interchange task, the centerpiece of the detail page is the Workflow Timeline — a chronological record of every event in the workflow from evaluation through determination or conversion letters.
Some prior authorizations start from a GoldCard schedule rather than a claim rejection. Those PAs follow the same timeline and states as any other PA. The summary header may show a GoldCard chip so you can tell the episode was proactive. When more clinical information is needed, the data-request letter uses GoldCard-oriented wording (proactive outreach before a rejection) instead of the usual rejection-driven data-request copy — you still work the request from the same Data Request / Remediation next-steps cards.
Reading the Workflow Timeline
The Workflow Timeline card appears on any task of type Prior authorization (initiation), PA continuation, or Therapy Interchange. At the top of the card you will see:
- Medication chip — the drug being reviewed.
- Workflow state chip — the PA’s current stage (see table below).
- Task status chip — the underlying task status (open, completed, etc.).
- GoldCard chip — appears when this PA was started from a GoldCard config (proactive outreach).
When a determination is available, a summary banner may appear above the event list with a plain-language summary of the PA status and a Next step line indicating what action — if any — is needed. Your organization controls whether that AI summary banner is shown; when it is turned off, Determination Review (below) is still available without the summary text. If a summary is still being generated and summaries are enabled for your tenant, you will see a progress indicator instead.
Below the summary, the timeline lists each event newest first — the most recent events, along with any current action items or next steps, appear at the top, and older events (evaluations, outbox communications, data requests, determinations, and transitions) follow beneath. Select any event to see its details.
When a determination came back denied, the PA Determination: Rejected event names the requirements the patient did not meet — for example Criteria not met: Body mass index (39156-5) ≥ 20 kg/m2 — using the same wording as the denial letter sent to the prescriber. If more than three requirements failed, the first three are listed followed by a count of the rest. Older denials whose stored detail cannot be resolved still read Patient does not meet criteria for therapy.
Determination Review
When clinical criteria are available for the determination, the timeline shows Determination Review with a Review button. If your tenant has Determination LLM summary turned on, a plain-language summary and Next step line appear above those controls; when the summary is off, you still open the same review panel without that text. Select Review to expand the panel, where you can walk through exactly how the determination was reached and gather any additional information you need before acting.
Clinical criteria tree
At the heart of the panel is the clinical criteria tree — a nested breakdown of the guideline rules that were checked against this patient. Criteria are organized into groups:
- All of the following groups require every item beneath them to be satisfied.
- One or more of the following groups require at least one item beneath them to be satisfied.
Each criterion shows whether it was satisfied:
- A green check with a Criteria met pill indicates the requirement was satisfied.
- A red X with a Criteria not met pill indicates the requirement was not satisfied.
When a guideline references a reusable ontology rule, the ontology rule’s name appears as a heading above the expanded list of diagnoses, drugs, procedures, or other criteria beneath it — so you can see both the clinical concept and the underlying codes that were checked.
When the overall determination did not pass, the tree is titled Clinical Criteria Not Met so you can quickly find the requirements that blocked the PA. Individual rows may show the patient’s own value alongside the requirement for context. The tree scrolls independently when it is long.
Documents
Alongside the criteria, the panel lists the patient’s documents. Select a document to preview it inline without leaving the timeline, so you can confirm supporting evidence while you review the criteria. Select the + next to Documents to upload a clinical document without leaving the review panel — the same upload flow as the rejected Next Steps card.
When previewing a PDF, use the Search document… box in the preview toolbar to find text inside the document — the PDF renders as an image, so your browser’s own find feature won’t work here. Type a term and press Enter to jump to the first match; the status (e.g. 3 / 12) shows your position, and the up/down arrows (or Enter / Shift+Enter) step to the next or previous match. For PDFs with selectable text, matches are highlighted on the page; for scanned documents, search jumps to the matching page without drawing highlight boxes.
Chart Updates
If your review surfaces missing or failed clinical criteria for this determination, select Enter Missing Clinical Data under Chart Updates. This opens the same criterion-guided form used in the rejected Next Steps card — each failed requirement shows the patient’s Current chart value next to the guideline Required value. Enter corrected observations, diagnoses, procedures, or medications where supported and save them directly to the patient chart. Saving updates the chart only — it does not re-run the evaluation.
When every criterion passed for this determination, the button is disabled and a short note explains that there are no failed clinical criteria to enter here.
Documents in the panel remain available for preview and corroboration while you review criteria and update the chart.
Timing, pausing, and completing
When you start a review, a timer begins next to the controls and counts up in minutes and seconds while the panel is open. Select Pause to step away mid-review — the panel collapses and the timer stops accumulating time, and selecting Review again resumes it from where it left off.
Select Complete when you have finished reviewing. This records the total time you spent reviewing, who completed the review, and when. After completing, the panel shows a “Reviewed by … · Nm Ns” summary in place of the timer controls, and this completed state persists — it stays visible when you return to the task later.
If the chart is updated or a new evaluation runs after you completed the review, that review is no longer current. The summary shows Review again instead of the completed summary. Select it to reopen Determination Review — the review timer resets and you walk through the criteria again with the latest evaluation and chart data.
Workflow States
| State | What it means |
|---|---|
| Initial | Evaluation complete; waiting for the next automated step |
| Data Request | A data-request letter has been sent to the prescriber |
| Remediation | A custom data request has been sent to gather additional clinical data |
| Approved | PA determination letter approved and sent |
| Rejected | PA determination letter denied and sent |
| Renewed | A continuing PA has been approved for renewal |
| Discontinued | The PA has been discontinued |
| Appeals | An appeal has been filed against the determination |
| Abandoned | The PA was manually abandoned without a determination |
| Excluded Medication | The medication is excluded from PA requirements |
| Failed | A system error prevented the PA from completing |
Next Steps When a Data Request Is Open
When the evaluation needs more clinical information, the PA moves to the Data Request or Remediation state and a Next Steps: Resolve Data Request card appears beneath the timeline. From here you can send a fax to the prescriber, upload a progress note, manually enter the data, or send a custom data request.
Once the requested data is present on the patient’s chart, the PA is fulfilled and re-evaluated. This happens automatically — as soon as all of the requested clinical data appears on the chart (for example, after you upload a document or add a medication, diagnosis, procedure, or observation), the system re-checks the open data request and re-evaluates the PA.
If you have just updated the chart and want to move things along right away rather than wait, select Re-evaluate now in this card. This button is always available while the PA is awaiting data — including when the data request already shows as fulfilled but the PA is still parked in the Data Request state. It re-evaluates this prior authorization against the current chart:
- If an open data request is now fully satisfied by the chart, it is fulfilled and you will see “Data request fulfilled from chart — re-evaluating this prior authorization.”
- Otherwise the PA is simply re-evaluated with the latest chart data, and you will see “Re-evaluating this prior authorization with the latest chart data.”
The timeline reloads either way so you always see the latest state.
Next Steps After a Rejection
When a determination comes back rejected, a Next Steps: Determination Rejected card appears beneath the timeline with the ways you can move forward.
If your organization requires staff review before communications go out, the card leads with a Deny & Send Communications action. This is the deliberate step that actually sends the denial — until you confirm, the denial letter and the PharmPix denial message are held.
Selecting Deny & Send Communications opens a Review & Confirm Denial dialog so you can check exactly what will be sent before anything leaves the system. The dialog shows:
- Denial details — the patient, the denial reason code, and the drug being denied.
- PharmPix denial message — the exact denial message that will be submitted (when PharmPix is enabled).
- Recipients — each recipient (prescriber, patient, pharmacy), the delivery status, and whether delivery is Manual or Automatic, with a link to that recipient’s letter.
- Denial letter preview — the generated denial letter shown inline so you can read it in place. When more than one letter was generated, links let you open each one.
Select Deny & Send to dispatch the held denial letter and, when configured, submit the PharmPix denial. A progress indicator streams the status, and the timeline refreshes automatically when the send completes. This action cannot be undone, so review the letter and message first.
The same card also offers two recovery options that do not send a denial:
- Add Data & Re-evaluate — stay on the workflow timeline while you gather missing clinical evidence. Use Upload Clinical Document to attach a progress note, or Enter Missing Clinical Data to open an in-workflow form that lists each failed criterion with the patient’s Current value next to the guideline Required value. For diagnoses, the entry-type dropdown (Current diagnosis / Not diagnosed / Never diagnosed) defaults from what the chart already shows — for example Not diagnosed when the chart already has that confirmation — and stays blank when the chart state is unknown; choose the value that matches the guideline requirement before saving. Enter corrected observations, diagnoses, and other supported chart values there and save them directly to the patient chart — saving does not re-run the evaluation. After the chart changes, a persistent banner may appear noting that the determination may be outdated (with the chart-modified time); use Re-evaluate Against Guidelines when you are ready. If the patient now meets criteria, an Approval step will appear for you to confirm and send communications. The same chart-changed banner can also appear after an approval when clinical chart data is edited later, so you know to re-check the determination against the updated chart.
- Force Approve — override the clinical rules and approve the PA when you have justification outside the automated criteria.
A Manually Transition option is always available to move the PA to another valid workflow state.
Manual Transitions
When a PA task requires a human decision, you can manually move the workflow to a new state using the Transition button in the upper-right corner of the Workflow Timeline card.
Selecting Transition opens a menu labeled Manual PA transitions with the following options (available options vary by current state):
| Action | When to use it |
|---|---|
| Approve | You are approving the PA. A determination letter will be sent and PharmPix will be updated if configured for automatic contact. |
| Deny | You are denying the PA. A determination letter will be sent and PharmPix will be updated if configured for automatic contact. |
| Abandoned | The PA will not be worked further. This marks it abandoned without creating any follow-up child tasks. |
| Remediation | Opens the custom data request dialog so you can gather additional clinical data from the prescriber. |
| Closed | Closes the PA and cancels any open child tasks. |
After you select an action (other than Remediation), a confirmation dialog opens titled Manually [action] PA. You must enter a Reason before the Confirm button becomes active. After you confirm, the timeline refreshes to show the new state.
When you choose Approve or Deny and more than one guideline was evaluated for this PA, the confirmation dialog asks you to select which guideline the decision applies to. Each evaluated guideline appears as a radio option with its indication label (for example, Type 2 Diabetes or Obesity). Choose one before Confirm becomes available. The selected guideline drives the determination — letters and downstream automation follow the same path as if that guideline had been the winning automated result. If the PA already has a primary guideline, that option is pre-selected when it appears in the list. When only one guideline applies, the dialog still shows that guideline so you can see what the decision will use — there is no choice to make.
Note on Approve and Deny: These options are not shown when the PA is already in an approved or denied state, respectively.
Note on Abandoned: This option is only available when the PA is in the Initial, Data Request, or Remediation state.
Approve & Send Communications
When your organization requires human review before determination letters go out, an approved or renewed PA with held communications shows a green Next Step: Approve & Send Determination card on the timeline.
Select Approve & Send Communications to open the Review & Approve Determination dialog. That dialog confirms you are about to dispatch the held letters (prescriber, patient, and pharmacy as applicable).
If the patient already has an active authorization on file for this drug, the dialog states plainly that PharmPix submission will be skipped — the letters still go out, but no new PBM submission is created. When no active authorization applies, the dialog includes PharmPix submission in the same approval step (when PharmPix is enabled for your organization).
Determination Letters on the Timeline
When a PA is approved, denied, or renewed, the timeline shows a Determination communication card with tabs for Prescriber, Patient, and Pharmacy. Each tab shows that recipient’s delivery status and mode (Manual or Automatic).
If a letter was Cancelled, Failed, Fax Failed, or Delivery Failed, select the affected recipient tab and choose Resend Letter (for automatic prescriber or pharmacy faxes) or Regenerate Letter (for patient letters or manual delivery). The system regenerates the PDF and, for automatic fax recipients, queues a new transmission. You can also open View Outbox Item for full delivery controls.
Use the Transition menu on an approved or renewed PA when you need to deny, request remediation, or close the workflow.
Related Items
On the task detail page, a Related Items section appears when the task is linked to an evaluation or to outbound letters. Selecting View Evaluation (or View Evaluation Details) opens the patient’s chart directly to the Evaluations section with that evaluation’s audit panel already open, so you can review the full criteria breakdown in context. If the task is missing a patient or guideline reference, the button falls back to opening the population-level evaluation run page instead. Use View Outbox Item to open each letter by recipient (prescriber, patient, or pharmacy).
For Therapy Interchange tasks the Workflow Timeline shows: the interchange workflow created event, the guideline evaluation result, and the conversion letter card (prescriber, member, and pharmacy recipients with their send status, View, and Download links). The PA-specific actions — Transition menu, data request steps, and PharmPix submission — are not shown for interchange tasks since they do not apply.
Sub-tasks
For every PA parent task, a Sub-tasks section appears below the Workflow Timeline. This table lists the child tasks that have been created automatically during the PA workflow — for example:
- Initiation — a PharmPix submission task
- Discontinue — a PharmPix revocation task
- Data request — a request for clinical data from the prescriber
- Rejection — a rejection-related communication task
Each sub-task shows its title, status, due date, and creation date. Select a sub-task row to open its detail page.
On a Rejection sub-task, a Rejection Details section lists the requirements the patient did not meet under a Criteria Not Met heading, each with the patient’s own value beneath it. These are the same requirements stated in the denial letter, so you can answer “why was this denied?” without opening the letter.
This wording is shown only for the determination that is currently in force. If the PA was re-evaluated after this rejection, the older rejection is marked Superseded and shows summary counts of the criteria it failed rather than the newer determination’s wording — so an outdated rejection never appears to have been denied for the current reasons. Open the live rejection to read the wording behind the denial that stands.
Child tasks of a PA workflow display a blue banner at the top of their detail page reading This task is part of a Prior Authorization workflow, with a View PA Workflow Timeline button that takes you back to the parent PA.
Error Banner
If the task or a PharmPix submission encounters an error, a red alert banner appears at the top of the task content area. The banner shows the error message. If a PharmPix-specific error is also present, it appears below the main error text.
For past errors, expand the Error History accordion (visible when system errors exist) to review the full history of errors and their timestamps.