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            Conduct an Admin Review of the Authorization Request

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            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.

            Required Editions

            Available in: Lightning Experience

            Available in: Enterprise and Unlimited Editions with Health Cloud
            User Permissions Needed
            To conduct an admin review: Health Cloud Utilization Management, OmniStudio User, and RuleEngine Runtime permission sets

            During an admin review, you verify whether:

            • The member has a member plan
            • The service requested is eligible for authorization
            • The provider is within the payer network
            • The required clinical documents were submitted.

            You can also reach out to the provider or member for additional documents.

            1. From the App Launcher, find and select the Utilization Management for Payers app.
            2. Select the case record to review.
            3. Click Start Admin Review.
            4. Verify eligibility status, authorization details, provider details, and clinical documents.
            5. If necessary, upload additional documents that you receive from the provider or member.
            6. In the Review Request window, indicate if the clinical documentation is Complete or Incomplete.
            7. In Notes, add a comment or observation about the request.
            8. When you’re done, click Submit to send the request for Nurse review.
             
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