Manage Authorization Requests in a Payer’s Office

Authorization for care requests typically requires a significant amount of administrative work, both by payers and providers. The review process can be tiresome and time-consuming, with multiple screen switches and data from various sources. To simplify and streamline this process, Utilization Management includes a number of guided workflows to help you handle authorizations efficiently.

• Authorization Request Process Flow in a Payer’s Office
  Utilization management’s comprehensive approach ensures that patients receive optimal medical care that’s delivered in the appropriate setting at the necessary time, while helping you properly manage high-cost care and hospitalizations.
• Simplify Authorization Request Reviews with the Utilization Management for Payers App
  The Utilization Management for Payers app provides a comprehensive view of authorization requests that are most important to you. The app shows all open cases, so that you can easily identify high priority and urgent requests, and take appropriate action effectively.
• Create and Submit Authorization Requests for Review
  As an intake coordinator, you often create and review care requests for need assessment. With information coming in from various sources—member plan details, provider information, care request details, and more—there’s increased chances of administrative errors.
• Conduct an Admin Review of the Authorization Request
  As an admin reviewer, you perform the first level of review for any authorization request that’s submitted by the intake coordinator.
• Conduct a Nurse Review of the Authorization Request
  As a nurse, you’re responsible for performing an effective clinical review of an authorization request to ensure healthcare services are compliant and are delivered with quality and cost efficiency.
• Conduct a Medical Director Review of the Authorization Request
  As a medical director, you’ve the final say on an authorization request. Similar to the utilization management nurse, you determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines.
• Manage Peer-to-Peer Reviews
  Peer-to-Peer review is the process where the medical director connects with the requesting provider to discuss the actual or potential reason for denial of an authorization request. These discussions provide transparency, help the medical director justify reasoning, and direct the provider towards appropriate care delivery, while avoiding lengthy dispute and appeal processes.
• Submit Care Requests with the Care Request Extensions Unmanaged Package
  You can use the Utilization Management app that’s part of the Health Cloud Care Request Extensions unmanaged package to submit requests. Care requests help you to work with a health plan to make sure that members get the appropriate care and providers get paid for their work. A care request includes the information such as member identifiers, a diagnosis, and the requested medication or service.
• Identify and Resolve Duplicate Prior Authorization Requests
  Compare the details of potential duplicates of a prior authorization request using a table and mark records as duplicates to close the associated case.