On this page:
   63.1    Solution Modules & Standards
  • Explanation
  • 63.0 Overview
  • 63.1 Solution Modules & Standards
  • 63.2 Actors, Roles & Data Scope
  • 63.3 Use Cases & Timeliness
  • 63.4 Security
  • 63.5 Glossary of Terms
    • 63.3    Use Cases & Timeliness   
    Table of Contents

    Actors, Roles & Data Scope

    63.2.1Actors and Roles

     

    The Prior Authorization Solution supports both providers and payers, allowing each to utilize the modules most relevant to their prior authorization processes.

    • Providers: Identify services that require prior authorization, generate and submit requests, receive responses, and manage the request lifecycle. Providers primarily interact with CRD and DTR to prepare requests and with PAS to submit and track them.

    • Payers: Receive, adjudicate, respond to, and track prior authorization requests in compliance with CMS and HIPAA standards. Payers primarily interact with PAS to process requests, provide real-time responses, and maintain audit history.

    63.2.2Data 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.
       63.1    Solution Modules & Standards
  • Explanation
  • 63.0 Overview
  • 63.1 Solution Modules & Standards
  • 63.2 Actors, Roles & Data Scope
  • 63.3 Use Cases & Timeliness
  • 63.4 Security
  • 63.5 Glossary of Terms
    • 63.3    Use Cases & Timeliness