SolutionS
Payer Prior Authorization Solutions
Speed the yes. Stop the waste.
Automated intake, evidence checks, and determinations that cut delays and denials at scale.
Payer Prior Authorization standardizes and accelerates medical necessity reviews from request to determination. Requests arrive through portals, EDI, fax, and APIs and are normalized into a single queue with eligibility, benefits, and duplication checks up front. Automated policy rules evaluate diagnosis, procedure codes, site of care, and documentation completeness against medical policies and evidence criteria, routing only exceptions to clinicians. Role-based workflows govern nurse and physician reviews with time-based SLAs, while audit trails, notices, and appeal packets are generated automatically.
Connectivity extends across providers and internal systems to reduce friction: real time status updates, document capture, and structured data exchange minimize back and forth and shorten cycle times. Dashboards track volume, turnaround time, approval rate, avoidable spends, peer-to-peer utilization, and overturns to spotlight optimization levers. Integrated outreach nudges providers for missing documentation and offers alternatives like in-network facilities or appropriate sites of care, improving member experience and medical cost outcomes.
Unified Intake and Normalization
Accept requests via portal, EDI, fax, and APIs; de-duplicate, validate member and provider data, and pre-check benefits and eligibility.
Rules-Driven Medical Policy Automation
Apply configurable clinical and administrative rules to triage, auto-approve, or route to nurse and physician review based on risk and complexity.
Clinical Review Workflows
Role-based queues, checklists, and collaboration tools for nurses, medical directors, and peer-to-peer interactions with tracked SLAs.
Documentation Management
Guided document capture, required evidence prompts, and structured clinical data ingestion to reduce cases pending review.
Provider Connectivity and Status
Real time status, notifications, and reason codes; secure upload and structured messaging to minimize back and forth.
Alternative Recommendations
Suggest in-network providers or appropriate sites of care when requests do not meet criteria, with documented rationale.
Determination, Notices, and Appeals
Auto-generation of approvals, partial approvals, and adverse determination letters; assemble appeal packets with full audit history.
Analytics and Optimization
Dashboards for TAT, approval rates, pend drivers, overturns, and peer-to-peer volume; test and tune rules to reduce friction and cost.
Compliance and Auditability
Full audit trails, role-based access, evidence retention, and standardized templates to satisfy regulatory and accreditation requirements.
Benefits
- Shorten authorization turnaround times with automated policy checks and streamlined clinical review.
- Reduce avoidable pends and denials by guiding complete submissions and ingesting structured clinical data.
- Lower medical costs by steering to in-network providers and appropriate sites of care when criteria are not met.
- Improve provider experience with unified intake, real time status, and fewer back-and-forth requests.
- Increase consistency and defensibility of determinations with governed rules, templates, and audit trails.
- Boost operational efficiency through role-based workflows, SLA tracking, and analytics-driven tuning.
- Enhance member experience by minimizing delays for necessary care and communicating clear next steps.
- Scale confidently across specialties and lines of business with configurable rules and interoperable integrations.