ChecklistGuro Insurance Verification and Authorization Process
Streamline your medical billing cycle with our comprehensive Insurance Verification and Authorization Process. Master the essentials of verifying patient coverage, obtaining prior authorizations, and preventing claim denials to ensure seamless revenue cycle management and optimized patient care workflows.
Start
Start of the Workflow/Process.
1. Fetch Patient Demographics
Retrieve patient information from the Patient Data Model to verify identity and coverage details.
2. Retrieve Insurance Policy Details
Fetch active insurance plan details and coverage limits from the Policy Data Model.
3. Create Verification Request
Generate a new 'Verification Request' entry in the Authorization Data Model to track the start of the process.
4. Perform Eligibility Check
Assign a task to the Billing Specialist to verify if the insurance policy is active and covers the specific procedure.
5. Calculate Co-pay and Deductible
Calculate the patient's out-of-pocket responsibility based on the retrieved deductible and co-insurance percentages.
6. Update Coverage Status
Update the Verification Request entry with the results of the eligibility check (Active/Inactive).
7. Clinical Documentation Review
Assign a task to the Medical Coder to ensure the clinical notes support the necessity of the requested procedure.
8. Get Procedure Codes
Retrieve the specific CPT/HCPCS codes requested for authorization from the Service Request Data Model.
9. Create Prior Authorization Submission
Create a new entry in the 'Auth Submissions' model to track the formal request sent to the payer.
10. Assign a task to the Authorization Coordinator to call the insurance company if no response is received within 48 hours.
Assign a task to the Authorization Coordinator to follow up with the payer if no response is received within the SLA.
11. Log Payer Response
Update the Authorization entry with the decision (Approved, Denied, or Pending) and the Auth Reference Number.
12. Calculate Total Estimated Revenue
Aggregate the estimated costs of all approved procedures in the current verification batch.
13. Notify Patient of Authorization Status
Send an automated email to the patient informing them whether their procedure has been approved or if more information is needed.
14. Alert Billing Department
Send an SMS notification to the Billing Manager when a high-value authorization is denied.
15. Generate Weekly Auth Denial Report
Generate a report summarizing all denied authorizations, reasons for denial, and payer trends for the week.
16. Cleanup Duplicate Requests
Delete any duplicate verification entries created by mistake during the intake process.
End
End of the Workflow/Process.
Start of the Workflow/Process.
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.
End of the Workflow/Process.
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