Pre-authorization request automation

Purpose

 1.1. Automate pre-authorization requests for anesthesiology services before procedures.
 1.2. Collect patient, procedure, and insurance data; generate and transmit requests to payers.
 1.3. Track payer responses and update provider and patient records.
 1.4. Reduce delays, manual errors, and administrative workload in billing workflows.

Trigger Conditions

 2.1. New procedure scheduled in EMR/EHR for a patient requiring anesthesia.
 2.2. Receipt of relevant clinical data and consent forms.
 2.3. Insurance eligibility check confirming need for pre-authorization.
 2.4. Update or change in scheduled procedure or provider details.

Platform Variants

 3.1. Epic Systems
  • Feature/Setting: HL7/FHIR interface; outbound event triggers for scheduled procedures to external endpoints.
 3.2. Cerner (Oracle Health)
  • Feature/Setting: Cerner Ignite APIs; monitor admission or pre-op modules, send API webhooks on new bookings.
 3.3. Allscripts
  • Feature/Setting: Allscripts Unity API; configure webhook on "ProcedureOrder" event.
 3.4. Kareo
  • Feature/Setting: Kareo API; use "AddProcedure" and "GetPatientInsurance" endpoints.
 3.5. Athenahealth
  • Feature/Setting: Athenahealth API; configure appointment webhooks to trigger automation flows.
 3.6. DrChrono
  • Feature/Setting: DrChrono API; "OnAppointmentCreate" webhook action and patient insurance API.
 3.7. eClinicalWorks
  • Feature/Setting: eCW API; appointment and insurance validation endpoints.
 3.8. Greenway Health
  • Feature/Setting: Intergy API; use "CreateEncounter" and "VerifyInsurance" functions.
 3.9. Change Healthcare
  • Feature/Setting: Electronic Pre-Authorization APIs; submit requests and track responses.
 3.10. Availity
  • Feature/Setting: Availity API Suite; "AuthorizationRequest" functions.
 3.11. CoverMyMeds
  • Feature/Setting: CoverMyMeds ePA API; transmit anesthesia-specific pre-auths.
 3.12. Outlook 365
  • Feature/Setting: Email send and receive automation for provider and patient notification on status updates.
 3.13. Google Workspace (Gmail + Sheets)
  • Feature/Setting: Google Apps Script API; log request data and send emails upon triggers.
 3.14. Salesforce Health Cloud
  • Feature/Setting: Flow Builders; automate outreach, status updates, and payer communication logging.
 3.15. Zoho CRM
  • Feature/Setting: Webhooks for new procedure entries; API to integrate insurance and payer data.
 3.16. Twilio SMS
  • Feature/Setting: Programmable SMS; send patient/provider updates on pre-authorization status.
 3.17. Slack
  • Feature/Setting: Incoming Webhooks; alert anesthesia team on approvals/denials.
 3.18. DocuSign
  • Feature/Setting: API trigger to request and store consent forms as part of pre-auth workflow.
 3.19. Zendesk
  • Feature/Setting: Ticket creation API for follow-up on delayed or denied pre-authorization.
 3.20. AWS Lambda
  • Feature/Setting: Orchestrate invocation on event triggers from EHR to call API logic for payer submission.
 3.21. Microsoft Power Automate
  • Feature/Setting: Scheduled/triggered flows integrating with EHR, payer API, and notifications.
 3.22. Medloop
  • Feature/Setting: API for pre-auth request tracking and escalation to clinical admins.

Benefits

 4.1. Decreases time to submission and receipt of payer determinations.
 4.2. Lowers claim denial rates due to incomplete or tardy requests.
 4.3. Minimizes manual workload for billing and compliance teams.
 4.4. Enhances visibility and documentation for audit trails.
 4.5. Improves patient satisfaction through proactive communication.