Insurance Verification and Authorization Process

Início do fluxo de trabalho/processo.

Retrieve patient information from the Patient Data Model to verify identity and coverage details.

Fetch active insurance plan details and coverage limits from the Policy Data Model.

Generate a new 'Verification Request' entry in the Authorization Data Model to track the start of the process.

Assign a task to the Billing Specialist to verify if the insurance policy is active and covers the specific procedure.

Calculate the patient's out-of-pocket responsibility based on the retrieved deductible and co-insurance percentages.

Update the Verification Request entry with the results of the eligibility check (Active/Inactive).

Assign a task to the Medical Coder to ensure the clinical notes support the necessity of the requested procedure.

Retrieve the specific CPT/HCPCS codes requested for authorization from the Service Request Data Model.

Create a new entry in the 'Auth Submissions' model to track the formal request sent to the payer.

Assign a task to the Authorization Coordinator to follow up with the payer if no response is received within the SLA.

Update the Authorization entry with the decision (Approved, Denied, or Pending) and the Auth Reference Number.

Aggregate the estimated costs of all approved procedures in the current verification batch.

Send an automated email to the patient informing them whether their procedure has been approved or if more information is needed.

Send an SMS notification to the Billing Manager when a high-value authorization is denied.

Generate a report summarizing all denied authorizations, reasons for denial, and payer trends for the week.

Delete any duplicate verification entries created by mistake during the intake process.

Fim do fluxo de trabalho/processo.