Prior Authorization Review

With a growing  emphasis  on Population  Health  Management  and  Pay for  Performance  (P4P), Healthcare  Payers  must support  all phases  and  types  of Services  Requests  and  Reviews (Prospective,  Concurrent,  and  Retrospective)  to ensure  their  members are  getting  the  right  level of care while  maintaining  the  high  standards  expected  in today's  competitive  market.

BIG’s  Prior Authorization  Review  (PAR)  App  reduces  complexity,  shortens  approval  cycles,  and builds  efficiencies  into  the  Continuum  of Care  that  can improve  delivery  of care effectiveness  in real-time.  

Member  Administrators  and  Clinical  Reviewers  can use the App  to expedite  responses to members resulting  in improved  patient  experiences  in this  often  frustrating  process.Organizationally  PAR  provides  ongoing  reporting  on  approvals,  denials,  pends  and  voids,  and  is capable  of handling  key  pieces  of member communications  such as approval  letters.  Acting  as data  HUB  for the  organization  to leverage  data  visibility  and  re-usability  for other  applications  as needed,  member organizations  increase  their  ability  to support  their  members Continuum  of Care and  mitigate  downstream  issues with  claim adjudication.

Request Intake

  • Standardized  Intake Entry forms  to document Prior  Authorization Requests
  • Integration  capabilities with  Member and Provider Directories
  • Search for industry standard Diagnosis and Service Code libraries to document encounter details

Administrative  Configuration

  • Create and manage decision logic to automatically approve, deny, or pend requests based on request  attributes
  • Configure work  queue auto  assignment based  on request  attributes Clinical Review
  • Individual work-lists for clinicians with  calculable due  dates based on request attributes
  • Enabled the ability to re-assign  requests to other queues/clinicians
  • Review and update request  details, including determination of the request  outcome
  • Extend previously approved or denied requests and submit for additional review
  • Generate Member letters summarizing request outcome

Operational  Reporting

  • Reporting dashboard summarizing request details
  • Report filtering  capabilities
  • Export summary grids to Excel

(This application was previously listed as Utilization Review.)