Prior Authorization
Empowering physicians to administer the necessary care when patients need it most —without hesitation.
Expedite Your Payer Approval
Learn the benefits of Prior Authorization for a fast, life saving, and cost effective insurance approval process.
Problem
Varying and ambiguous state and federal rules leave patients in the dark and providers forced to delay necessary treatment.
• No Insight — Patients have no insight or knowledge about approval or denial.
• Up in the Air — It takes days, weeks, or longer to receive a decision.
• Delays — Dangerous treatment delays for acute, chronic and complex conditions.
• Financial and Administrative Burden — Costly provider and payer misalignment.
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Solution
• Da Vinci Payer Data Exchange (PDex) Prior Authorization Profile — Enables payers to communicate prior authorization decisions and any changes directly to patients.
• Explanation Of Benefit Resource is used by PDex to express claims information to members with the CARIN Blue Button® FHIR® Implementation guide (CARIN BB IG).
• CARIN Blue Button® IG — Can be customized to include or exclude prior authorization records:
— Pending and active decisions
— Related clinical documentation
— Forms for items and services (not including prescription drugs)
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Benefits
• Fast Answers — Receive an answer no later than one (1) business day after a provider initiates prior authorization for the enrollee.
• Clarity — Clear understanding of pending versus active decisions and related clinical documentation or forms (not including prescription drugs).
— List of approved units and services
— Approval and ending date record
— Changes of status
• No Care Delays — Patients receive the right care at the right time.
• Reduced Administrative Burden — Healthcare providers greatly reduce operational and financial burden with quicker and automated process.