Utilization Management / Authorizations & Referrals / Auto-Approval Config
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Auto-Approval Configuration

Define rules for straight-through processing of low-risk authorization requests without manual review

Auto-Approved (MTD)
68%
Straight-through rate
False Positive Rate
1.2%
Below 2% threshold
Active Rules
6
Of 8 configured
Avg TAT (auto)
<1m
Instant processing
Auto-Approval Rules
Rule Name Service Type Clinical Criteria Member Criteria Threshold Status
Office Visit PCP Outpatient E&M Active PCP relationship Plan A/B, Age 18+ ≤ 4/yr
Lab — Routine Panel Diagnostic Lab ICD-10 match list All eligible members ≤ 6/yr
Physical Therapy Outpatient PT MSK diagnosis + Rx No recent surgery ≤ 12 visits
Radiology — Standard Imaging (X-Ray, US) Ordering provider in-network All eligible members ≤ 3/episode
Preventive — Annual Wellness / Preventive Age-appropriate screening All eligible members 1/yr
Specialist Follow-up Specialty OP visit Prior approved referral exists In-network specialist ≤ 3 follow-ups
Advanced Imaging MRI / CT Scan Linked diagnosis required No prior same-episode ≤ 1/episode
Mental Health OP Behavioral Health HCPCS H-code match Mental health benefit active ≤ 20/yr
Performance Metrics
Rule Effectiveness
Auto-Approval Rate68%
False Positive Rate1.2%
Clinical Criteria Match94%
Member Criteria Match89%
Rule Editor — Physical Therapy (edit mode)
 Page Guide
Overview
Auto-Approval Config lets you define rules for straight-through processing (STP) — authorizations that meet all criteria are approved instantly without manual review, reducing TAT from days to seconds.
Rule Components
  • Service Type: CPT or category of service the rule applies to
  • Clinical Criteria: Diagnosis, prescription, or clinical requirements
  • Member Criteria: Eligibility, plan, or demographic conditions
  • Threshold: Quantity or frequency limit for auto-approval
Testing Rules
Use Test Rule to run a new or modified rule against the past 30 days of authorization data. Review the simulated auto-approval rate and false positive rate before enabling in production.
False Positive Management
A false positive is an auto-approved case that would have been denied on manual review. Keep this rate below 2% to maintain clinical integrity. Rules above 2% FP are automatically suspended.