Recommended Services Pathway for Payers

Payers can access this dashboard on the Case record pages. Add and apply a filter for the case or care request record IDs to see recommendations specific to a record.

• The Services Pathway tab: See the services that are likely to be received by payers in the recommendation duration selected when creating the app, and the probability of receiving the services as part of an authorization request. Understand whether the recommended services are part of the current authorization request, have been received as part of an existing authorization request, or are expected to be received in an upcoming authorization request. Segregate recommended services by service codes or drug codes. See the recommended services that are more than or equal to a likelihood percentage by selecting the percentage using the slider and sort the services based on the likelihood percentages.

  Payers can create a set of conditions based on these recommendations for the recommendation duration and autoapprove services that meet these conditions after the authorization requests are received. This business flow can automate clinical approvals and support quicker clinical review determinations.

  

• The Member History tab: See previously submitted services authorization requests for a member and the services authorization requests’ status. Segregate the submitted services by service codes or drug codes. See the services that are created in a specific duration by selecting the duration using the slider, and sort them based on created dates.