Health Cloud Administration
jAuthorization Request Process Flow in a Payer’s Office
Utilization management’s comprehensive approach for payers ensures that patients
receive optimal medical care that’s delivered in the appropriate setting at the necessary time,
while helping users properly manage high-cost care and hospitalizations.
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Available in: Lightning Experience Available in: Enterprise and Unlimited Editions with Health Cloud |
With a highly refined process and solid technological workflows, Utilization Management’s process flow helps your payer users achieve improved health outcomes and operational efficiencies. Let’s see how:
- The Intake Specialist or Coordinator creates an authorization request based on the details the provider or member shares. They check the eligibility of service requested, add information related to the request, update provider details, and add supporting documents.
- The Admin Reviewer then performs the first level of review to verify member eligibility, check availability of required documents to support clinical review, and verify provider’s network status.
- The Utilization Management Nurse performs a clinical review of the request by referring to the payer’s internal guidelines and industry standard medical necessity guidelines. The nurse either approves a request or marks it for further review by the medical director.
- The Medical Director provides the final determination for requests they receive. By analyzing the observations of previous reviewers against respective services, diagnosis, clinical documents, and medical guidelines, they get a 360-degree view of the request and are able to quickly make an informed decision.
Occasionally, if the medical director denies or partially approves a request, a peer-to-peer review meeting is scheduled between the medical director and requesting provider. This meeting helps to clarify follow-up questions, exchange views, and align both parties on a decision.