Clinical Workflow and Documentation AutomationPurpose
1.2. Automate mapping of clinical documentation (diagnosis, procedure codes, medical history) to pre-authorization form requirements.
1.3. Auto-generate and auto-submit insurance pre-authorization requests to payers’ APIs, automating document upload, attachment of physician notes, and prior auth forms.
1.4. Automate status tracking and auto-notification to pediatric neurologists and practice admins upon payer decision or if additional information is needed.
1.5. Automate record updates back to EHR upon successful authorization or request for more details.
1.6. Automate creation of audit trail for compliance and appeals.
Trigger Conditions
2.2. Clinician adds specific diagnosis or procedure code tagged for required prior authorization.
2.3. Referral order from primary care or other specialist marked as “requires pre-authorization.”
2.4. System detects incomplete/in-action authorization on existing cases.
2.5. Insurance company response or action needed event detected via webhook/API poll.
Platform Variants
3.1. Epic EHR
• Feature/Setting: Outgoing HL7/FHIR event triggers, App Orchard API; configure push on “new referral” event.
3.2. Cerner Millennium
• Feature/Setting: Cerner Open Developer Experience (code.on.cerner.com), FHIR Subscription; configure data trigger on new encounter or order.
3.3. Athenahealth
• Feature/Setting: Athenahealth API – Appointments & Orders endpoints; configure webhook for new procedure order.
3.4. DrChrono
• Feature/Setting: EHR API, “New Appointment Created” and “Clinical Note Finalized” webhook events.
3.5. NextGen Healthcare
• Feature/Setting: NextGen API – Encounter and Order endpoints with notification options.
3.6. Allscripts
• Feature/Setting: Allscripts Unity API, patient encounter subscription; automate extraction and updates.
3.7. AdvancedMD
• Feature/Setting: RESTful API event polling for new procedures or scheduled appointments.
3.8. Greenway Health
• Feature/Setting: Greenway Web Services API; trigger on clinical documentation upload or code assignment.
3.9. Salesforce Health Cloud
• Feature/Setting: Health Cloud API – patient timeline events, Flow automation for authorization object creation.
3.10. Availity
• Feature/Setting: Availity APIs for Prior Authorizations; automate form creation, submission, and status polling.
3.11. Change Healthcare
• Feature/Setting: Medical Network APIs; automate ePA (electronic Prior Auth) with status and response retrieval.
3.12. Surescripts
• Feature/Setting: Surescripts electronic prior authorization API for medication pre-auth on neurology meds.
3.13. Redox
• Feature/Setting: Redox FHIR/HL7 data integration; configure automation triggers for pediatrics workflows.
3.14. Google Cloud Healthcare API
• Feature/Setting: DICOM/FHIR/HL7v2 event triggers; automate data aggregation and forwarding to payer endpoints.
3.15. AWS HealthLake
• Feature/Setting: Automated FHIR data event trigger and Lambda automation for rule-based cases.
3.16. UiPath
• Feature/Setting: RPA bot for automating legacy EHR UI steps and document upload.
3.17. Microsoft Power Automate
• Feature/Setting: Automated cloud flows with healthcare connectors; configure for FHIR entry event.
3.18. MuleSoft
• Feature/Setting: API-led connectivity to EHR/Payer/CRM, automate orchestration of auth process.
3.19. Workato
• Feature/Setting: Workbot auto-flow for extracting patient/order data and pushing to insurance APIs.
3.20. IBM App Connect
• Feature/Setting: Automated workflows linking EHRs, payer APIs, and case management.
3.21. Box
• Feature/Setting: Automated upload and secure sharing of clinical documents with payers.
3.22. DocuSign
• Feature/Setting: Automated e-signature capture for physician certifications if required in pre-auth.
Benefits
4.2. Eliminates manual data re-entry by automating clinical-to-payer data workflows.
4.3. Automator reduces insurance denials due to incomplete or late information.
4.4. Automation improves regulatory compliance with complete audit trails.
4.5. Automatedly alerts providers to payer actions, automating follow-up for missing or additional requirements.
4.6. Automates documentation in EHR, minimizing staff workload and errors in the prior auth process.