Insurance Prior Authorization
Automated system that evaluates insurance requirements for medical services based on carrier rules, diagnosis codes, and service details.
Solution
This insurance authorization system streamlines healthcare administrative workflows by automatically determining when prior approval is needed for medical services. The solution evaluates multiple factors including the patient's insurance type (Medicaid, Medicare, or Commercial), specific diagnosis codes, service category, CPT/HCPCS codes, and associated costs.
For each insurance type, the system applies carrier-specific rules to determine authorization requirements. Medicaid evaluations focus on service costs, with thresholds varying by service type. Medicare determinations analyze procedure codes and service categories, while Commercial insurance assessments include specialty medication indicators and specific procedure code lists. The system also identifies clinical exceptions where authorization requirements are waived, such as chemotherapy encounters, pregnancy-related services, and COVID-19 imaging studies, regardless of the initial determination.
How it works
The system follows a structured decision process:
- Input Processing: Captures patient insurance information, diagnosis codes, service type, and details including CPT/HCPCS code, cost, and emergency status.
- Insurance Classification: Routes the request to the appropriate ruleset based on insurance type (Medicaid, Medicare, or Commercial).
- Rule Application: Applies carrier-specific criteria based on service type and details:
- Medicaid: Evaluates service cost thresholds
- Medicare: Reviews procedure codes and service categories
- Commercial: Checks specific procedure lists and specialty designations
- Clinical Exclusion Review: Examines diagnosis codes to identify exceptions that waive authorization requirements, such as chemotherapy, pregnancy, or COVID-19 related services.
- Final Determination: Generates a timestamped decision with clear reasoning for the authorization requirement or exemption.
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