Streamlined prior authorization submission workflows

Purpose

1.1. The automation of prior authorization submission workflows is designed to eliminate manual form filling, minimize documentation errors, and accelerate the prescription approval process for diabetologist practices.
1.2. Automates extraction of patient and prescription data from EHRs or PMS, transmits structured prior authorization requests to payers, retrieves status updates, and notifies staff/patients with outcomes.
1.3. Streamlines communication among doctors, pharmacies, and insurance providers, allowing for more reliable, automatable, and automatedly managed prescription approval cycles for diabetes medications/devices.

Trigger Conditions

2.1. New diabetes prescription requiring insurance prior authorization is generated.
2.2. Refill request flagged as requiring payer approval.
2.3. EHR or PMS updates reflecting a new or modified prescription entry.
2.4. Pharmacy or staff triggers manual “prior authorization needed” indicator in workflow.
2.5. Insurance coverage changes detected through automated eligibility checkers.

Platform variants

3.1. Epic EHR
• Feature/Setting: “Orders” API endpoint; automate pulling new diabetes prescriptions and submitting via FHIR prior-auth resource.
3.2. Cerner Millennium
• Feature/Setting: “care_orders” webhook; automate triggering workflow when new medication order created.
3.3. Allscripts
• Feature/Setting: Unity API “Medication Orders” listener; automate pushing prescription data to prior authorization engine.
3.4. Athenahealth
• Feature/Setting: “OnCreate Encounter” webhook; automation for detecting diabetes Rx and invoking payer prior-auth API.
3.5. Practice Fusion
• Feature/Setting: “Export to API”; automate sending prescription details to prior auth systems.
3.6. Surescripts
• Feature/Setting: “Prior Authorization and Formulary APIs”; automation for direct payer submissions and status polling.
3.7. CoverMyMeds
• Feature/Setting: “ePA API”; automate structured PA request creation, status tracking, result retrieval.
3.8. Change Healthcare
• Feature/Setting: “ePA FHIR API”; automates bidirectional PA workflow with insurers.
3.9. Availity
• Feature/Setting: “Authorization API”; automate eligibility checks and PA submissions via REST API.
3.10. Salesforce Health Cloud
• Feature/Setting: “Health Cloud EHR Data Model/Apex triggers”; automate status updates in patient records.
3.11. Redox
• Feature/Setting: “Orders/Authorization Data Model”; automate data exchange between EHR and external prior auth systems.
3.12. Par8o
• Feature/Setting: “Referral API”; automate prior auth requests when prescription is entered.
3.13. Meditech
• Feature/Setting: “Web API for Ordering”; automate fetching and sending orders to PA handler.
3.14. Health Gorilla
• Feature/Setting: “Prior Auth API”; automation for combining Rx and clinical info for payer submission.
3.15. NextGen Healthcare
• Feature/Setting: “EHR Integration API”; automate transmission of Rx requiring PA.
3.16. MuleSoft
• Feature/Setting: Prebuilt Healthcare Connectors; automate PA with robust mapping of EHR to Payer formats.
3.17. Google Cloud Healthcare API
• Feature/Setting: “FHIR Store”; automate transformation and secure routing of PA requests.
3.18. AWS HealthLake
• Feature/Setting: “CreateFHIRResource”; automate archiving and automated submission of PA requests.
3.19. Microsoft Cloud for Healthcare
• Feature/Setting: “FHIR Service/Logic Apps”; automate rule-based PA triggers.
3.20. eClinicalWorks
• Feature/Setting: “eBO Reports + API”; automate extraction and automated transmission of eligible Rxs for PA.

Benefits

4.1. Automates complex, multi-party prior authorization steps, reducing administrative lag and errors.
4.2. Automated notifications and faster payer response, leading to reduced Rx delays for diabetes patients.
4.3. Minimizes manual data errors and duplications through structured, automatable workflows.
4.4. Improves documentation accuracy; achieves compliance through automated audit trails.
4.5. Increases patient satisfaction by automating approvals and communication, supporting provider efficiency.