Prior Authorization Review

Overview

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 reusability for other applications as needed, member organizations increase their ability to support their members access to timely care and mitigate downstream issues with claim adjudication.

Key Features & Functionality

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.
• Capture Clinical Notes and Documentation.

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 worklists for clinicians with calculable due dates based on request attributes.
• Configure duration of request reviews based on type and urgency of the request.
• 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.)