Insurance and revenue
Prior authorization automation, settled before the visit.
Checked against payer policy, filed and tracked to an answer before the visit.
Prior authorization status, Maria L.
- Procedure
- MRI lumbar spine, CPT 72148
- Payer
- Commercial PPO
- Visit
- Nov 18, 9:30 AM
- Auth required
- Yes, policy p. 14
- Submitted
- Fax, Nov 6, 9:14 AM
- Decision
- Approved Nov 8
- Auth number
- PA-77310
- Units and dates
- 1 unit, valid to Dec 31
- Written to chart
- Yes
The claim for this visit carries PA-77310 automatically.
Every missed authorization is a denied claim, and every slow one is a patient who waits. Getting it settled before the visit protects both the schedule and the revenue.
Before
the visit, not after the denial
Every
rule backed by the payer's own policy text
The auth board
Every pending request on one board, sorted by where it is stuck.
Planned procedures arrive from EHR orders or from staff entry and move left to right as the work gets done. The badge counts days in the current stage.
Prior auth tracker, this week
Needed2
James O.
CPT 97110, Medicare Advantage
0 daysPriya S.
CPT 70553, Commercial HMO
1 dayDocs gathered1
Leo T.
CPT 29881, Commercial PPO
1 daySubmitted2
Ana R.
CDT D4341, Dental PPO
2 daysOmar K.
CPT 95810, State Medicaid
3 daysPending1
Grace W.
CPT 73721, Commercial PPO
7 daysDecided2
Maria L.
CPT 72148, PA-77310
ApprovedBen H.
CPT 64483, Medicare Advantage
DeniedGrace W. is past the payer's stated turnaround, so a status call is already queued.
Work arrives on its own
A new EHR order or a procedure added by staff creates the card.
Days in stage, not days since booking
The count resets each time a request moves, so a slow payer and a slow internal step look different on the board.
Denials leave the board with a next step
A denial goes to staff with the payer's reason and the appeal window.
What prior authorization automation should take off your desk
Good prior authorization automation answers three questions for every planned service: is auth required, has the request gone in with what the payer asks for, and what is the current prior authorization status. It should then put the auth number on the chart without anyone retyping it.
Most clinics have someone who knows the answers for their top payers. The trouble is the long tail: the plan that changed its imaging list last quarter, or the sleep study that only needs auth in a lab. 2care does the lookup, paperwork and chasing, and leaves clinical calls with your team.
Is auth required?
Three sources checked, and an unclear answer stays unclear.
The eligibility reply, the payer's policy document and the payer's free text can disagree. The safe answer is the one that protects the claim.
Grace W., MRI knee, CPT 73721
Result
Required
All three sources agree. Request opened and documents requested from the chart.
Where the rulebook comes from
Only verified payer policy answers the auth question.
Payer policy documents are collected, stored byte for byte, read into rules, checked, and verified by a person before any version is allowed to answer a question.
What it does with policy
- Keeps every version of a payer policy so an answer can be traced to the document in force that day
- Quotes the exact line and page number behind each rule
- Flags a code that is missing from the list as Not on the list
- Marks rules that depend on site of service, units or diagnosis as Depends
What it will not do
- Answer from an unverified policy version
- Turn Unknown or Not on the list into not needed
- Make a medical necessity judgement for your providers
Documentation worklist
Missing paperwork becomes a task before the payer asks.
Each payer lists what a request needs. 2care pulls what it can from the chart and turns each gap into a named task, so the request does not go out thin and come back as needs info.
Leo T., knee arthroscopy, CPT 29881
| Item | Status |
|---|---|
| Order with ICD-10 M23.221 | Working |
| Office notes, last 2 visits | Working |
| 6 weeks of physical therapy | Working |
| Imaging report | Working |
| Member ID and group | Working |
Task for front desk: confirm the MRI date with the imaging center.
How a request reaches each payer
Payers do not agree on how they want auth requests, so 2care uses whatever channel each one accepts.
Fax
A PA request fax goes out with the supporting documents attached. The reply fax is read into approved, denied or needs info.
Payer portal
The request is entered and documents uploaded in the payer's portal, then its status is checked on a schedule.
Electronic request
Where the payer accepts an X12 278 request, it is sent electronically and the response is read back into the tracker.
Phone
For phone-only payers, the call is placed and the rep name and reference number are logged.
Follow up until decided
Status is re-checked after a set number of hours. A request past the payer's turnaround triggers a call rather than another wait.
Reading the reply
A reply fax turned into a decision on the chart.
Payer decisions arrive as faxed letters. 2care reads the page, pulls the fields that matter and attaches the original to the request.
Inbound fax, 3 pages
Utilization review determination
Re: Request for outpatient advanced imaging
Member: Maria L. Service: CPT 72148
Determination: APPROVED
Authorization number PA-77310
Approved units: 1 Valid through 12/31
Services outside these dates require a new request.
Low confidence on any field sends the page to staff review before it is written.
One request, start to finish
The full history behind a single auth number.
Every action on a request is logged with a time and a channel, so the question of what happened with this auth has one place to look.
Maria L., MRI lumbar spine
Auth check
Nov 5, 4:02 PMRequired, policy p. 14
Submitted
FaxNov 6, 9:14 AMPA request with notes and order
Status check
PhoneNov 7, 9:20 AMPending clinical review
Reply fax read
FaxNov 8, 11:41 AMApproved, PA-77310
Written to chart
Nov 8, 11:42 AM1 unit, valid to Dec 31
Visit
Nov 18Auth number on the claim
Rep name and call reference from Nov 7 are stored with the request.
See it work
Coverage confirmed before the patient arrives
Deductible, copay, coinsurance and whether the MRI needs prior auth, all from one payer call, with the reference number on file.
Insurance and revenue
The rest of the workflow.
Before you switch it on
Prior auth questions from billing leads.
It checks whether each planned visit or procedure needs authorization, gathers the documents the payer asks for, submits the request by fax, portal, electronic request or phone, follows the prior authorization status until there is a decision, and writes the auth number, units and dates to the chart.
It combines three sources: the auth flag in the eligibility reply, the payer's verified policy document, and any free text the payer returns. If any one of them says required, the answer is required. Every rule from a policy carries the quote and page number it came from.
The answer is Not on the list, which is shown separately from Not required. 2care never treats a missing code as not needed. Staff see the sources that were checked and can confirm with the payer.
From orders in your EHR, or from staff entering a planned procedure. Either way the auth check runs straight away.
Yes. The tracker shows every request by stage, Needed, Docs gathered, Submitted, Pending and Decided, with the days it has spent in its current stage, so overdue requests stand out.
No. It takes on the lookup, paperwork and follow-up. Staff still own medical necessity, peer to peer reviews, appeals strategy and any request where the answer is Depends or Unknown.
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