The Prior Authorization Certified Specialist (PACS) program is a comprehensive, 12-module, self-paced, online program designed to foster the professional development of the Prior Authorization Specialist. The Prior Authorization Certification demonstrates that professionals have met rigorous standards through intensive study, self-assessment and evaluation.

The PACS certification is the most comprehensive training program in the world. Achieving the PACS demonstrates the highest standards of knowledge, and excellence in the prior authorization field.

It also sets the stage for continual professional development through values centered on lifelong learning. The curriculum serves to provide intermediate level material which is meant to establish a minimum level of core competencies we believe are important for all prior authorization professionals.

The curriculum focuses on 5 key areas:

I. Prior authorizations including definitions, history and the evolution of the prior authorization process, defining the roles of the prior authorization professionals, understanding the complete process from provider through payer to patient

II. Fundamentals before the prior authorization including medical compendia, ICD- 10 codes, CPT and the medically accepted indication

III. Insurance guidelines, researching the plan effectively, communication and initiating a prior authorization request from the provider’s office

IV. Coverage Determinations of the medication prior authorizations and processing the request from the payer’s side

V. Authorization denials and appeals and other authorization needs and tasks.

Program Goals

  • Provide a solid foundation within various areas in prior authorization to increase the chance of success.
  • Offer the most comprehensive training to allow prior authorization professionals the opportunity to work within a variety of areas within the healthcare industry.

Program Learning Outcomes

  • Align the direction and goals of the prior authorization process by better understanding the cross functional areas that relate to prior authorization process such as Insurance plans and policies, understanding the differences in Service-line and Pharmaceutical prior authorizations, and understanding the different roles of healthcare professionals that are involved in the prior authorization process.
  • Understand the use of Medical Compendia as it related to Medication and Service-line prior authorizations.
  • Learn about the process of submitting a prior authorization request for medications and services with best practices from the provider’s offices.
  • Learn about the process of receiving a prior authorization request at the payer’s side and the steps that are entailed to approve or deny the request.
  • Learn about the process of denials and appeals.
  • Broaden your knowledge in the prior authorization field and gain an understanding of the complete process from the patient, provider and insurance plan.

Program Format

The PACS program is online and self-paced. Individuals are given access to all program materials for six months.

The program consists of 12 modules. Each module contains a post-quiz, goals and learning objectives. The post-quizzes are meant as progress indicators. The program also includes case studies, and a glossary of terms and a tool kit.

Time needed to complete: It's a self-paced program, but on average most learners complete the program within 4 weeks (approximately 10 hours)

*Learners have 6 months to complete the certification

What you will learn?

  • Define Healthcare Authorizations
  • Gain basic knowledge of each healthcare professional’s role in processing a PA request
  • Insurance company and payer overview
  • Know the difference between a medication prior authorization and service prior authorization
  • Understand what a medically accepted indication is
  • Understand the importance and use of Compendia
  • Develop a system to obtain and apply ICD-10 codes
  • Develop a system to obtain and apply CPT codes
  • Learn about the Authorization steps for submitting a request
  • Communication of the prior authorization request
  • Researching and Using guidelines from insurance plans
  • Learning about PCP to specialist, Inpatient authorizations, Out of network waivers
  • Learning about appeal of authorization denials
  • Learn about the different coverage determination types of medications
  • The Future of Prior authorizations
  • Job opportunities and salary ranges