Prior Authorization Module
End-to-end prior authorization management including submission, clinical review, auto-approval rules, denial management, and EDI 278 processing for utilization management.
Organization Relevance
How It Works
Authorization requests enter the system through provider portals, EDI 278 transactions, or manual entry. The auto-approval engine evaluates requests against clinical criteria and organizational rules. Requests not auto-approved route to medical review for clinical determination. Approved authorizations generate EDI 278 responses. Denials trigger appeal workflows. The system tracks all authorization activity for utilization reporting and compliance.
Requirements
- Clinical criteria library (InterQual, MCG, or custom)
- Medical Director or authorized clinical reviewer staffing
- EDI 278 connectivity with trading partners
- CMS/state-mandated turnaround time compliance
- Integration with claims for authorization matching
Target Audience
Utilization Management Teams, Medical Directors, Provider Relations, Claims Processing Teams
Pages (9)
| Page | Purpose | Key Features |
|---|---|---|
| Auth Dashboard | Overview of authorization queue, turnaround metrics, and pending reviews | Queue management, TAT tracking, Status distribution, Alert indicators |
| Auto-Approval Rules | Configure rules for automated authorization approval based on clinical criteria | Rule builder, Criteria mapping, Approval rate tracking, Rule versioning |
| Clinical Criteria | Manage clinical criteria libraries used for medical necessity determination | Criteria library, Version management, Mapping to procedures, Effectiveness tracking |
| Denial Management | Track and manage authorization denials, peer-to-peer reviews, and appeals | Denial tracking, Appeal workflow, Peer-to-peer scheduling, Outcome analytics |
| EDI 278 Processing | Electronic prior authorization request and response processing via X12 278 | Inbound processing, Response generation, Error handling, Transaction monitoring |
| Medical Review | Clinical review workflow for authorization requests requiring medical director review | Review queue, Clinical documentation, Decision recording, Letter generation |
| Network Authorization | Manage in-network vs out-of-network authorization requirements | Network rules, OON authorization, Gap exception handling, Network status verification |
| Prior Auth Submission | Submit and track prior authorization requests with clinical documentation | Request submission, Document upload, Status tracking, Communication log |
| Referral Management | Manage provider-to-provider referrals and specialist authorization | Referral submission, Specialist matching, Authorization linking, Follow-up tracking |
API Integrations
X12 278 Request/Response (EDI)Da Vinci Prior Auth FHIR APIClinical criteria lookup APIAuthorization status inquiry APIProvider portal submission API
Referenced Resources
X12 278 Health Care Services ReviewCMS Medicare Advantage Prior Auth requirementsDa Vinci Prior Authorization Implementation Guide (FHIR)NCQA UM Standards
Expected Results
Streamlined authorization workflow with faster turnaround, clinical criteria consistency, regulatory compliance, and reduced administrative burden through auto-approval.