Eligibility and prior authorizations
Two screens that tackle the biggest cause of denied claims: treating a patient without valid coverage or without authorization. Under Eligibility you register the member's coverage and run the check with the payer. Under Authorizations you drive a procedure's prior authorization from draft to appeal, with an SLA, an authorization number and an approval rate.
Both screens sit in the Health menu, as Eligibility and Authorizations. They solve different problems, in this order: first you find out whether the patient has coverage, then, when the procedure requires it, you request the authorization.
Registering the coverage
- Open Eligibility.
- Under New coverage, choose the Patient.
- Fill in Payer, Plan and Member ID.
- Choose the Relationship from Holder and Dependent.
- Click Add.
The coverage joins the list with Patient, Plan, Member ID and Status, which can be Active, Inactive or Suspended. A patient can have more than one coverage, which is common when there is a personal plan and an employer plan.
Checking eligibility
On the coverage row, click Check. The result can be Eligible, Ineligible, Needs authorization or Not checked. Click History to see the earlier checks for that coverage.
Two deliberate rules govern that result. The first: it is always dated, and an old check appears flagged as Stale. You never look at a result without knowing how old it is. The second: the answer informs the front desk and billing, and it does not decide the patient's care. An unfavorable answer is a signal to check with the payer, not an instruction to refuse treatment.
The real query is made by a provider connected by your institution, following the industry standards. While no provider is configured, the system honestly answers Not checked instead of inventing a favorable answer. If you want genuine automatic checking, talk to whoever administers your CRM integrations.
Opening a prior authorization
- Open Authorizations.
- Under New authorization, choose the Patient.
- Describe the Procedure.
- Choose the Priority from Routine and Urgent.
- Click Open. The authorization starts as Draft.
At the top of the screen there are four indicators: Total, Open, Overdue and Approval rate. The approval rate is the management reading that shows whether the problem is in how you fill out the request or in the payer.
Driving it to the end
Use Advance on the authorization row. The path is chained and the screen only offers the destinations that are valid from the current state: from Draft to Submitted, from Submitted to In review or Pending info, from In review to Approved, Partial or Denied. From Partial or Denied you can go to Appealed, and from Appealed the authorization goes back to In review. Cancelled is available at almost every point and is a dead end.
When the authorization is approved, the system asks for the authorization number, which is what billing will need later. When it goes to appeal, it asks for the reason. Authorizations that blow through the SLA are flagged as Overdue and counted in the Overdue indicator.
Limits and common questions
- Nothing here contains clinical information. The Procedure field is an administrative description of what was requested.
- Electronic submission to the payer depends on an integration configured by the institution. Without it, the flow still works as an internal record of what was requested, when and with what outcome.
- Can I reopen a cancelled authorization? No. Cancelled is a dead end. Open a new authorization.
- Does an eligibility check cost anything? That depends on the provider your institution contracts. The CRM stores the dated result so you do not repeat the query for nothing.
- Why does the screen show the result date all the time? Because coverage changes. An Eligible from thirty days ago proves nothing today.