PA Determination
Determine if prior authorization is required for a procedure
PA Determination checks whether prior authorization is required for a specific procedure (CPT code) with a specific insurance provider (payer). The system uses configured rules to return a decision for each CPT code and payer combination.
Running a determination
Click Determination in the sidebar menu to open the determination modal.
Fill in the required fields:
Payer
Yes
Select an accepted insurance provider
CPT/HCPCS Codes
Yes
Select one or more procedure codes
Click Check Determination to run the check.
The system evaluates each CPT code against the selected payer and returns a decision.
Decision types
Required
Prior authorization is required for this procedure with this payer
Not Required
Prior authorization is not required
Undetermined
No rule has been configured for this CPT code and payer combination
Results are color-coded:
Required — red
Not Required — green
Undetermined — gray
After viewing results, click New Check to clear the form and run another determination.
Running from a treatment
PA determinations can also be run directly from a treatment's detail page as part of the treatment workflow.
Open a treatment detail page.
In the workflow steps section, click Run PA Check on the PA Determination step.
The system automatically checks each of the treatment's CPT codes against the insurance providers linked to the treatment. Results are saved as decision records on the treatment and the workflow step status is updated accordingly.
Viewing determination results on a treatment
On the treatment detail page, the PA Determination workflow step displays all linked decisions:
Decisions are grouped by CPT code and insurance provider
Each group shows the latest decision with its date and any notes
Older decisions can be expanded to view the full decision history
How determinations work
The system uses a rules-based approach:
Each rule defines whether prior authorization is required for a specific CPT code and payer combination.
Rules have an effective date — the most recent rule with an effective date on or before today is used.
If no rule exists for a CPT code and payer combination, the decision is Undetermined.
How PA determination connects to other features
Treatments
PA determination is a workflow step in the treatment lifecycle. Running it from a treatment saves decision records and updates the workflow.
Payer Network
Determinations are evaluated per payer. Only accepted payers are available for selection.
Prior Authorizations
A Required determination indicates that a prior authorization should be submitted for the procedure.
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