Statuses

Move a request between statuses with the Update status menu in the top bar of the Overview screen. Most statuses apply immediately; three of them open a dialog to collect required information first. Every status change stamps the review date and updated by on the record.

Pending Records

When to use: the request is in but the supporting medical records have not arrived yet.
What happens: direct update — no dialog.
Next: move to Pending Review once the records are attached.

Pending Review

When to use: records are in and the request is waiting on TPA review. This is the status the TPA queue view filters on — everything in your work list is here.
What happens: direct update — no dialog.
Next: after review, one of TPA Approved, Denied, or Medical Director.

TPA Approved — Pending Underwriting

When to use: the request meets guideline criteria and you are authorizing visits, pending PCH underwriting.
What happens: opens the TPA approval dialog. All fields are required except the criteria checkboxes:
- Conservative care criteria — check what is documented: Has at least 5 chiropractor visits · Has at least 2 pain management visits.
- Effective date and Expiration date of the authorization.
- Visits requested / authorized / used / remaining.
- Result — summarize the decision and the guideline applied (e.g. LCD reference).

TPA approval dialog

Next: underwriting moves the request to Approved.

Approved

When to use: the authorization is fully approved.
What happens: direct update — unless the request is currently Denied, in which case an override dialog opens and requires an override reason (e.g. Peer review completed, Additional records received, Medical director override, Appeal granted).
Next: scheduling — Appointment Scheduled.

Denied

When to use: the request does not meet criteria, or required documentation was never provided.
What happens: opens the deny dialog. A reason is required — explain what is missing or which criteria were not met. The provider is notified with the reason you enter.

Deny dialog with required reason

Next: a denial can be overturned later via Approved (override reason required — see above).

Medical Director

When to use: the case needs physician-level peer review before a determination — escalations, borderline criteria, appeals.
What happens: direct update — no dialog. Add a note with the question you are escalating.
Next: back to Pending Review (or straight to a determination) once the medical director responds.

Appointment Scheduled

When to use: the authorized care has been scheduled with the provider.
What happens: direct update — no dialog. The Appointments card on the Overview shows the scheduled visits.

Quick reference

Status	Dialog?	Required fields
Pending Records	—	—
Pending Review	—	—
TPA Approved — Pending Underwriting	Yes	Effective + expiration dates, 4 visit counts, result
Approved	Only when currently Denied	Override reason
Denied	Yes	Reason
Medical Director	—	—
Appointment Scheduled	—	—

Pending Records​

Pending Review​

TPA Approved — Pending Underwriting​

Approved​

Denied​

Medical Director​

Appointment Scheduled​

Quick reference​