Actors and Roles
The Prior Authorization Solution supports Payers as Smile Digital Health customers. The Solution allows Payers to offer Electronic Prior Auth services to Providers. The Providers are not deploying the SDH Prior Auth solution, they will instead be leveraging standards based APIs to consume services from the solution. The systems used by Providers to consume the APIs created by this solution are out of scope.
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Payers
- Customers of the Prior Auth Solution from Smile Digital Health.
- Receive, route and orchestrate incoming CRD, DTR, and PAS requests.
- Integrate to back-end systems to provide relvant documentation requirements, adjudicate prior auth requets
- Integrate to Delegates for selected requests (e.g. all medical imaging related requests)
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Delegates
- Service suppliers to Payers.
- Not direct customers of the solution
- Provide some or all prior auth services (e.g. Medical Necessity Policies)
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Providers
- B2B peers of Payers, jointly providing health care services to Patients (Members)
- Not direct customers of the solution
- Leverage APIs provided by the solution to prepare and submit Prior Auth requests.
- NOTE: The Prior Auth solution does not deploy any components to the Providers.
Data Scope
The Prior Authorization Solution enables secure electronic exchange of data required for prior authorization workflows. The data scope includes:
- Service and coverage information: Details about the procedure, service, or medication being requested, including codes and modifiers.
- Clinical documentation: Relevant clinical data required to support the request, captured via templates in DTR.
- Authorization requests: Initial submissions, updates, and cancellations handled through PAS.
- Responses and adjudication: Approval, denial, or requests for additional information, returned in real-time.
- Audit and tracking information: Identifiers, timestamps, and status history for compliance and reporting purposes.