63.3.1Use Cases

The Prior Authorization Solution enables streamlined workflows for both providers and payers. Key example scenarios include:

63.3.1.1Provider Request Submission

1. A provider uses CRD to check if a procedure requires prior authorization.
2. If required, DTR provides templates and rules to prepare the necessary clinical documentation.
3. The provider submits the prior authorization request through PAS, which sends it electronically to the payer.
4. The provider receives real-time responses, including approval, denial, or requests for additional information.

63.3.1.2Payer Request Processing

1. A payer receives a prior authorization request via PAS.
2. The payer adjudicates the request based on coverage policies, clinical rules, and documentation completeness.
3. The payer sends a structured electronic response back to the provider, indicating approval, denial, or a request for additional information.
4. The payer maintains audit and tracking data for compliance and reporting purposes.

63.3.1.3Status Tracking and Updates

1. Providers can check the status of previously submitted requests via PAS.
2. Providers may submit updates, additional documentation, or cancellations as needed.
3. Payers receive these updates, adjudicate accordingly, and send updated responses.
4. Both parties have visibility into the request lifecycle, reducing administrative back-and-forth and ensuring timely decision-making.

63.3.2Timeliness

The Prior Authorization Solution is designed to support efficient and timely workflows, reducing delays for both providers and payers. Key features include:

• Faster decision-making: Providers can check coverage requirements and submit requests electronically, reducing manual effort.
• Status tracking and updates: Providers can query the status of requests, submit additional documentation, or cancel requests through the PAS API.
• Reduced administrative overhead: Automation of coverage checks and documentation through CRD and DTR minimizes back-and-forth communications.
• Improved patient care: Streamlined workflows help ensure prior authorization decisions are made as quickly as possible, supporting timely delivery of healthcare services.