Utilization Management’s solution for providers gathers necessary clinical information
from the Electronic Health Record (EHR) system and establishes a connection with the clearing
house or payer system. With this seamless integration, provider users can efficiently create and
submit authorization requests and deliver timely care to patients.
Required Editions
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Available in: Lightning Experience
Available in: Enterprise and Unlimited Editions with Health
Cloud
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When a patient books an appointment or visits a provider, the patient’s diagnosis and service
information are updated in the EHR. Before the provider can proceed with the treatment for the
patient, an authorization request must be submitted to the payer. The authorization coordinator
on staff at the provider’s office is responsible for handling the end-to-end authorization
process of the patient’s services. On receiving an approval for the requested services from
the payer, the provider can proceed with care delivery.
Let’s see how authorization coordinators manage requests:
- View and retrieve patient information, clinical data (diagnosis and service), requesting
and servicing provider details, and more from the EHR system.
- Check if authorization is necessary for the requested services or diagnosis from the
payer.
- Create and submit authorization requests with the necessary details and documents to the
payer based on the defined requirements.
- Follow up on the status of the submitted request.
- Provide additional information to the payer to enable prompt decision making.
- Receive the determination in a timely manner so that patient care is delivered as
planned.
- After the request is approved, submit approval reference details to the payer for
processing claim submissions. If the request is denied, raise an appeal request with the
payer for reconsideration or request a peer-to-peer meeting.
