Medication prior authorization

How do we get a medication prior authorization approved by gathering the clinical criteria and the history, submitting to the payer, and returning the result to the prescriber and the patient?

Start from the formulary's criteria and the chart, not from a blank form. When a prescription needs approval, Callvu prefills the request from the EHR (the patient, the coverage, the prescriber, the medication, the diagnosis, the relevant history, the medications tried), classifies the payer's criteria for the drug (the step therapy, the diagnosis and the lab or test requirements, the quantity limits, the specialist requirement), chases the missing evidence from the chart or the prescriber through a link, assembles and submits the request through the payer's electronic prior authorization channel, tracks the payer's decision on its clock, routes a denial or a request for a peer review to the prescriber in the Decision Desk with the appeal options, and writes the result (the approval with its validity, or the denial with the reasons) to the EHR and tells the patient and the pharmacy. Live at Ministry of Health, under national rules outside the US.

Live at Ministry of HealthComplex: multi-party handoffsCallvu moves: prefill, chase and verify, decide, write back

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Last updated November 7, 2026.

The problem today

The patient left the pharmacy without the medication, and the prior authorization form was still on the printer in the clinic.

Today, without Callvu

A prescription is rejected at the pharmacy for prior authorization. The pharmacy faxes the clinic; the clinic's staff find the payer's form, look up what the drug requires, pull the chart, and fax it back; the payer responds in days; nobody tells the patient. The medication starts a week late or not at all. The clinic spends hours a day on this.

The payer's formulary rules define the criteria for each drug: the diagnosis, the step therapy (the alternatives tried and failed), the labs or tests, the quantity limits, the prescriber's specialty, the duration of the approval. Most of the evidence is in the chart. The electronic prior authorization standard lets the request go to the payer with the evidence attached and the decision come back in the same channel. The clock is the payer's; the tracking is the clinic's.

An authorization assembled from the chart against the criteria is approved on the first submission far more often.

How it runs

From the requestto the system of record.

A prescription requires prior authorization (a rejection from the pharmacy, a formulary check at prescribing, or the prescriber's request). Callvu opens the authorization from the order.

Prescriber and clinic staff: Supply the evidence the chart lacks through a link, and decide denials and peer reviews in the Decision Desk.
Payer or pharmacy benefit manager: Receives the request and returns the decision through the electronic channel.
Patient: Is told the status and the result, and any next step.
Pharmacy: Is told the approval so the medication can be dispensed.
Callvu: Prefills, classifies the criteria, chases, submits, tracks, routes and writes.

Prefill and classify the criteria
The request is prefilled from the EHR (the patient, the coverage and the plan, the prescriber and their specialty, the medication with the dose and quantity, the diagnosis codes, the medication history including the alternatives tried and the outcomes, the relevant labs and tests); the payer's formulary criteria for the drug are classified (the covered diagnoses, the step therapy requirement, the required labs or tests, the quantity limits, the specialist requirement, the approval duration) and each criterion is matched to the evidence in the chart.
Chase and verify the evidence
A criterion without evidence in the chart (a failed trial of an alternative not documented, a lab not on file, a specialist's note) is requested from the prescriber or the clinic through a link with the specific gap; the evidence is read and checked against the criterion; the request is assembled with the evidence attached and the prescriber's attestation.
Decide and submit
A complete request is submitted through the payer's electronic prior authorization channel (or the portal or fax where the payer has no electronic channel), and the payer's decision is tracked on its clock with the patient told the status; an approval proceeds by rule; a denial, a request for more information, or an offer of a peer-to-peer review goes to the prescriber in the Decision Desk with the payer's reasons and only the allowed outcomes (supply more evidence and resubmit, accept the peer review and book it, prescribe the alternative, or appeal through the appeal process).
Write back
The result (the approval with its number, validity period and quantity, or the denial with the reasons) is written to the EHR against the order, the pharmacy is told the approval so the medication is dispensed, the patient is told the result and the next step, and the renewal process is scheduled before the approval expires.

Where it ends: The authorization was assembled from the chart against the payer's criteria, submitted electronically with the evidence, tracked on the payer's clock, and the result reached the EHR, the pharmacy and the patient, with the renewal scheduled. The Decision Trace shows the criteria, the evidence mapped and any decision; the Audit Trace shows the chases, the submission and the decision with time.

Runtime enforcement

What is enforcedwhile the work runs.

The regulations preloaded in Callvu Studio and the bank's own policies, applied as steps that run, not lines in a binder. A step that breaks a rule does not run, so a completed run was compliant.

Regulations

US requirements shown. Ministry of Health runs this process under national rules outside the US; Callvu loads each market's rules as policies the same way.

Payer formulary rules: Each payer's or pharmacy benefit manager's formulary sets the prior authorization criteria per drug (the diagnoses, the step therapy and the documented trials and failures, the required labs or tests, the quantity and duration limits, the prescriber specialty) and the approval duration and renewal requirements; the request must evidence each criterion, and the decision periods follow the plan's rules and the applicable regulations (for example the Medicare Part D coverage determination periods of 72 hours standard and 24 hours expedited, and the state prior authorization laws with their periods).
Electronic prior authorization standards (the NCPDP SCRIPT ePA transactions, the CMS Part D ePA requirement, the CMS Interoperability and Prior Authorization rule for the medical benefit): Medication prior authorizations may be sent and answered electronically through the adopted standard with the questions and the attachments in the transaction, which the process uses where the payer supports it; the payer's decision and reasons return in the same channel.
HIPAA Privacy Rule (45 CFR 164.506) and the patient notice requirements: The disclosure of the chart evidence to the payer is a payment disclosure limited to the minimum necessary; the patient is informed of the decision and the appeal rights under the plan's rules.

Company policies

The request starts from the chart and the payer's criteria, with each criterion mapped to evidence before submission.
A criterion without evidence is a specific request to the prescriber, never a blank form.
The payer's decision is tracked on its clock, and the patient is told the status.
The EHR is the system of record for the authorization, and the pharmacy and the renewal run from it.

Controls

EHR prefill of the request.
Formulary criteria classification and evidence mapping.
Prescriber chases for missing evidence.
Electronic submission with attachments.
Decision tracking and Decision Desk for denials and peer reviews.
EHR write, pharmacy and patient notification, renewal scheduling.

Clocks and deadlines

Payer decision: The plan's period from submission (for example 72 hours standard and 24 hours expedited under Medicare Part D), tracked with escalation.
Evidence chase: Reminders to the prescriber on the schedule, with the patient's wait in view.
Approval validity: The period on the approval; the renewal process opens before it expires.

Documents and checks

The prefilled request and the criteria mapping
The evidence as received and checked
The submission and its confirmation
The payer's decision and any prescriber decision
The EHR record and the notifications

In the Decision Trace

The criteria and the evidence mapped to each.
The submission.
Any decision and the prescriber.

In the Audit Trace

Each chase and arrival with time.
The submission with time.
The decision with time, the write and the notifications.

The handoff

Between the front doorand the back office.

The front door

The pharmacy's rejection, the formulary check at prescribing, or the prescriber's request; the prescriber supplies evidence through a link; the patient sees status.

The back office

The clinic's staff stop faxing; the prescriber decides only denials and peer reviews.

The Decision Desk

A denial, a request for more information or a peer-to-peer offer goes to the prescriber in the Decision Desk with the payer's reasons and only resubmit with evidence, book the peer review, prescribe the alternative, or appeal.

Proof

Live at Ministry of Health.Published results only.

Each result is a published claim, with its code on agents.callvu.com, where its status, source and last verified date are kept.

The Ministry of Health hospital network runs 23 hospitals on Callvu and keeps adding more, with 3x faster procedure approvals, 78% faster patient consent and more than 1M pages of paper eliminated.

HLT-01 · Self-asserted · verified 2026-11-05

At the Ministry of Health, Callvu integrated with very old legacy systems at several hospitals, and brings ERP, CRM and EHR data into one experience.

HLT-05 · Customer-attested · verified 2026-11-05

At the Ministry of Health, a process chains up to five patient forms and signatures and ten internal steps; completing one step starts the next, for example surgery consent starts anesthesia consent and sends the procedure to the approving committee.

HLT-02 · Customer-attested · verified 2026-11-05

Questions

What buyers ask next,answered plainly.

What is prefilled?

The patient, the coverage, the prescriber, the medication, the diagnosis, the medication history with the alternatives tried, and the relevant labs from the EHR, mapped to the payer's criteria for the drug.

What does the prescriber do?

Supplies through a link only the evidence the chart lacks for a specific criterion, attests, and decides denials and peer reviews in the Decision Desk.

How does the patient find out?

They are told the status while the payer decides and the result when it arrives, with the pharmacy told the approval so the medication is dispensed.

Related processes

Scheduled-procedure prior authorization Authorization renewals and extensions Peer-to-peer review scheduling Payer document requests Try it in the sandbox All healthcare processes

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