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            Authorization Request Overview

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            Authorization Request Overview

            Medications, surgeries, personalized therapies, and healthcare treatments can all lead to huge bills for payers and patients. Many of these expensive procedures can be avoided or replaced by simpler, cost-effective alternatives that take place in outpatient settings. To verify cost of care and medical necessity of procedures and treatments, payers must conduct authorization reviews of the care requests that providers raise.

            Required Editions

            Available in: Lightning Experience

            Available in: Enterprise and Unlimited Editions with Health Cloud

            But authorization reviews are often manual and highly dependent on variable factors such as care type and admission type, requiring you to switch between various processes to collate information. From need assessment to coverage benefit verification, authorization can be a lengthy process.

            To ensure ease of access to information and smoother collaboration between payers and providers, Health Cloud’s Utilization Management provides these capabilities:

            • Centralized and guided process workflows that empower intake specialists, admin reviewers, nurses, and medical directors to easily handle authorization requests
            • Integrated payer app for seamless review processing
            • Automatic administrative checks based on rules
            • Controlled access based on request status
            • Context-specific notes for clinical documents, service codes, and more
            • Service-level agreement (SLA) tracking, along with analytics-based insights on SLA violations, during the review process
            • Custom reports to analyze care request data
            • Queue routing for streamlined approval process
            • FHIR Da Vinci Health Record Exchange aligned APIs, deployed on MuleSoft, for uninterrupted request processing
            • FHIR R4 aligned data model for interoperability and integration with external systems
             
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