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WORKFLOW - HEALTHCARE

Prior Authorization Decision Workflow

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Quick Answer

The Prior Authorization Decision Workflow uses AI to evaluate medical necessity against payer-specific criteria, identify documentation gaps, and generate authorization submission packages. This workflow reduces PA processing time by 60% while improving first-pass approval rates by 35%.

Definition

**Prior Authorization Decision Workflow** automates the evaluation of clinical documentation against payer medical policies. AI matches clinical indicators to criteria, identifies missing evidence, and generates compelling medical necessity arguments.

Key Points

  • Retrieves patient history and clinical documentation from EHR
  • Matches clinical indicators to payer-specific medical necessity criteria
  • Identifies documentation gaps before submission
  • Generates medical necessity rationale with clinical evidence
  • Creates complete authorization submission package
  • Provides peer-to-peer preparation materials if needed
  • Reduces PA processing time from days/hours to minutes
  • Improves first-pass approval rates by 35% on average

How It Works

1

Request Intake

Receive authorization request from provider: procedure/medication requested, diagnosis codes, clinical rationale, supporting documentation.

2

Patient History Retrieval

Pull patient history from EHR: previous treatments, diagnoses, medications, test results, prior authorizations.

3

Payer Criteria Matching

Retrieve payer-specific medical necessity criteria for requested service. Map clinical indicators to criteria requirements.

4

Documentation Gap Analysis

Identify missing documentation: required test results, specialist consultations, treatment history, clinical notes.

5

Medical Necessity Evaluation

Evaluate whether clinical evidence meets payer criteria. Generate medical necessity rationale with supporting evidence.

6

Authorization Package Creation

Compile complete submission: request form, medical necessity letter, clinical documentation, test results, treatment history.

7

Confidence Scoring

Provide approval likelihood score (0-100). Flag cases likely to be denied for enhanced documentation or peer-to-peer.

8

Submission & Tracking

Submit to payer via portal, fax, or API. Track authorization status and alert on decision or delays.

Decision Logic: Clinical Evidence → Payer Criteria → Medical Necessity

Inputs: Clinical documentation (notes, test results, imaging), patient history, diagnosis codes, requested service/medication, provider rationale

Payer Criteria: Medical necessity guidelines, coverage policies, prior authorization requirements, step therapy protocols, quantity limits

Constraints: HIPAA compliance, documentation completeness requirements, submission deadlines, appeal timelines

Outputs: Authorization decision recommendation, medical necessity rationale, documentation package, approval likelihood score, gap identification

When to Escalate to Clinical Review

  • •Low approval likelihood score (<60%) requiring enhanced documentation
  • •Clinical evidence incomplete or contradictory
  • •Experimental or investigational procedure requiring medical director review
  • •Payer criteria ambiguous or conflicting
  • •Patient's clinical scenario not well-represented in payer guidelines
  • •High-value authorization (>$50K) requiring additional oversight