Insurance authorization and billing

Step-by-Step Breakdown

Detailed explanation of each automated stage in the workflow.

1. 1

   Trigger

   Patient authorization request initiated

   A new patient admission or service renewal triggers the insurance authorization workflow. The system pulls patient demographics, insurance details, and proposed care plan from the patient management system.

   AxxessAlayaCare
2. 2

   Action

   Verify insurance eligibility

   System automatically queries insurance databases to verify patient coverage, benefits, and authorization requirements. Real-time eligibility checks confirm active coverage and identify specific authorization protocols.

   BrightreeHomecare Homebase
3. 3

   Action

   Generate authorization request

   Automated creation of prior authorization requests using patient clinical data, physician orders, and care plan details. The system populates required forms and attaches supporting documentation.

   AxxessMatrixCare
4. 4

   Decision

   Check authorization approval status

   System monitors authorization responses and determines if approval was granted, denied, or requires additional information. Workflow branches based on insurance company response.

   BrightreeClearCare
5. 5

   Action

   Process approved authorizations

   For approved authorizations, the system updates patient records with authorization numbers, coverage periods, and visit limits. Care schedules are automatically adjusted based on approved service parameters.

   AlayaCareHomecare Homebase
6. 6

   Action

   Generate and submit claims

   Automated billing claim creation using completed visit documentation, authorization details, and billing codes. Claims are electronically submitted to appropriate insurance payers with required attachments.

   MatrixCareBrightree
7. 7

   Output

   Deliver billing reports

   System generates comprehensive reports showing authorization status, submitted claims, payment tracking, and denial management alerts. Reports are distributed to billing staff and administrators for review.

   AxxessClearCare

Related Home Health Articles