Insurance verification and pre-authorization

Step-by-Step Breakdown

Detailed explanation of each automated stage in the workflow.

1. 1

   Trigger

   Patient appointment scheduled

   A new patient appointment is created in the EHR system that requires insurance verification or pre-authorization. The system automatically detects procedures that need prior approval.

   EpicCerner
2. 2

   Action

   Extract patient insurance data

   Retrieves patient insurance information, policy details, and demographic data from the EHR system. Validates that all required fields are complete for verification request.

   EpicCernerAthenahealth
3. 3

   Action

   Submit eligibility verification request

   Sends automated eligibility and benefits verification request to the insurance payer through electronic data interchange. Checks coverage status, copay amounts, and deductible information.

   AthenahealthDrChronoKareo
4. 4

   Decision

   Evaluate pre-authorization requirement

   Analyzes the procedure codes and insurance response to determine if pre-authorization is required. Routes to appropriate next step based on payer requirements.

   EpicAthenahealth
5. 5

   Action

   Submit pre-authorization request

   Generates and submits pre-authorization request with clinical documentation, procedure codes, and medical necessity justification. Tracks submission status and reference numbers.

   EpicCernerAthenahealth
6. 6

   Action

   Update patient record

   Records verification results, authorization numbers, coverage details, and patient financial responsibility in the EHR. Flags any issues for staff review.

   EpicCernerPractice Fusion
7. 7

   Output

   Generate verification summary report

   Creates comprehensive report showing insurance verification status, pre-authorization approval, patient responsibility amounts, and any required follow-up actions for the care team.

   EpicAthenahealthDrChrono

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