Automated insurance verification and pre-authorization

Purpose

1.1. Automate real-time insurance verification and pre-authorization for oral surgery patients, automating intake, eligibility checks, policy validation, and approval processes to decrease manual effort and errors.
1.2. Automates instant eligibility checks on insurance networks, coverage verification, plan limits, and co-pay amounts automatically before appointments.
1.3. Automating submission for pre-authorization requests directly to insurers, receiving, processing, and tracking approval status with automated updates sent to staff and patients.
1.4. Automates documentation and audit trails for compliance, securely storing all insurance verification and authorization records.

Trigger Conditions

2.1. Automating upon new patient appointment scheduling or check-in event.
2.2. Automates when new or updated insurance information is entered in the EHR or PMS.
2.3. Automatedly triggers on patient forms submitted via web, mobile apps, or intake kiosks.
2.4. Automates when treatment codes for oral surgery are added to a patient case file.

Platform Variants

3.1. AdvancedMD
• Feature/Setting: Automated API-driven insurance eligibility check — Configure API endpoint /insurance/eligibility for real-time verification.
3.2. Dentrix
• Feature/Setting: Automate DxWeb API to auto-pull insurance details and automate request submissions.
3.3. Open Dental
• Feature/Setting: Automates through e-claims and automation triggers to verify coverage when new appointments are booked.
3.4. Epic
• Feature/Setting: Bridges “Real-Time Eligibility” automation in the ADT module for surgery scheduling events.
3.5. Athenahealth
• Feature/Setting: InsuranceEligibility API automator connected to schedule or chart update triggers.
3.6. Kareo
• Feature/Setting: Kareo API automates batch eligibility verification for daily or hourly patient lists.
3.7. eClinicalWorks
• Feature/Setting: Automator for the insurance verification web service API, auto-initiated via SmartForm submit.
3.8. Cerner
• Feature/Setting: Automates through RTE (Real-Time Eligibility) HL7 messaging interface, triggered by surgical encounter.
3.9. Change Healthcare
• Feature/Setting: Eligibility & Benefits Verification API automator, configured for inbound patient demographics.
3.10. Availity
• Feature/Setting: Availity Real-Time API — Use automator to send automated EDI 270/271 transactions.
3.11. Zocdoc
• Feature/Setting: Automate integration with insurance verification at appointment confirmation via Zocdoc API.
3.12. Salesforce Health Cloud
• Feature/Setting: Automator for insurance object triggers, invoking Service Cloud flows for pre-authorization.
3.13. Greenway Health
• Feature/Setting: Practice Automation Services for eligibility and auth; automate nightly batch checks.
3.14. Meditech
• Feature/Setting: Automate integration through MAGIC NPR report triggers for appointment scheduling events.
3.15. Nexhealth
• Feature/Setting: Automated API call on booking to verify insurance and pre-auth requirements via platform connector.
3.16. DocuSign
• Feature/Setting: Trigger automated insurance document signature flows on eligibility event.
3.17. MuleSoft
• Feature/Setting: Mule flow to automate EDI and API integration with insurance carriers upon intake.
3.18. HL7 (using Mirth Connect)
• Feature/Setting: Automate HL7 interface to send ADT and trigger eligibility queries on new patient message.
3.19. Redox Engine
• Feature/Setting: Automate data event triggers for insurance verification at patient engagement points.
3.20. SAP Health Engagement
• Feature/Setting: Automated workflow template for insurance pre-auth upon surgical order entry.

Benefits

4.1. Automates reduction of administrative workload and speeds up patient processing.
4.2. Eliminates manual insurance data entry errors and automates real-time information accuracy.
4.3. Automates compliance and audit requirements for insurance verification.
4.4. Automator-approved faster pre-authorization improves surgery scheduling flow and revenue cycle.
4.5. Automates improved patient experience—automatedly informing them of eligibility and coverage upfront.
4.6. Automating processes enhances transparency and patient trust in oral surgery practices.