Insurance verification and pre-authorization

Step-by-Step Breakdown

Detailed explanation of each automated stage in the workflow.

1. 1

   Trigger

   Appointment scheduled requiring authorization

   Patient books appointment for procedure like Mohs surgery, laser treatment, or biopsy that requires insurance pre-authorization. System automatically detects authorization requirement based on CPT codes.

   Epic EHRModernizing Medicine EMA
2. 2

   Action

   Extract patient insurance details

   System pulls patient insurance information, policy numbers, and coverage details from EHR. Validates current insurance card on file and coverage effective dates.

   Epic EHRModernizing Medicine EMA
3. 3

   Action

   Verify coverage eligibility

   Automated eligibility check confirms active coverage, deductible status, and specific dermatology benefits. System queries insurance provider databases in real-time.

   Epic EHRInsurance API
4. 4

   Decision

   Check if pre-authorization required

   System determines if specific procedure requires pre-authorization based on insurance plan requirements and procedure codes. Routes to appropriate next step based on authorization needs.

   Epic EHRInsurance API
5. 5

   Action

   Submit pre-authorization request

   Automatically generates and submits pre-authorization request with patient demographics, diagnosis codes, procedure details, and supporting clinical documentation. Tracks submission status.

   Epic EHRModernizing Medicine EMA
6. 6

   Action

   Monitor authorization status

   System periodically checks authorization status and updates patient record. Sends automated reminders to staff for pending authorizations approaching deadline.

   Epic EHRModernizing Medicine EMA
7. 7

   Output

   Generate verification summary

   Creates comprehensive report with insurance verification results, pre-authorization status, patient financial responsibility, and any required follow-up actions for clinical staff.

   Epic EHRModernizing Medicine EMA

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