Our Payer Solutions
How Can We Help?
We offer a variety of solutions to help payers streamline and automate prior authorization:
All Solutions Are
Simple and Secure
Our innovative, flexible platform is built to streamline and automate the prior authorization process, enabling a touchless solution. With an open-API framework, our products can operate as a comprehensive suite or as standalone components tailored to meet specific payer needs. By reducing manual intervention and ensuring policy transparency, we simplify prior authorizations, delivering efficiency and compliance with every use.
- Secure, HIPAA compliant, and certified to SOC 2 and HITRUST standards
- Can be implemented using a phased approach
- Gain compliance with state and federal regulations
- Intuitive interface and user-friendly design
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Modular, API-based solutions designed for seamless integration with existing systems
- Robust reporting
Payer Benefits
Multiple Product Benefits Create Value Across Organization
- Reduce Provider Calls and Boost Call Center Efficiency
Payers using our solutions report reduced provider call volume and tangible savings, while customer service teams resolve prior authorization inquiries faster, improving efficiency.
- Reduced Prior Authorization Processing Costs
Payers report radically reduced volume of PA submissions with our solutions due to the reduction in unnecessary prior authorization requests. This volume reduction translates into immediate savings on utilization management activities.
- Maximize ROI with Enhanced Provider and Member Satisfaction
Our solutions deliver ROI by streamlining prior authorizations, reducing administrative burden, and boosting provider and member satisfaction. We enhance efficiency and empower customer service teams to create seamless, value-driven experiences.
- Comprehensive Tracking and Reporting
Our solutions establish a clear audit trail for both payer and provider to allow easy investigation and verification of past decisions.
Our Solutions
PA Checkpoint
A provider, member, or call center user can quickly get an accurate answer to the question, "Is a prior authorization required?" by entering 3-4 pieces of information. PA Checkpoint provides a structured database and transparency application for prior authorization rules and policy metadata. It includes API interfaces for the PARDD Coverage Requirement Discovery (CRD) transaction, health plan website, provider portal, and connections to other health plan systems. Configuration is streamlined through API connections, spreadsheet imports, or an intuitive administrative portal.
Policy Management
Supports the payer in their efforts to create, maintain, and share policies. The creation function of the application includes intelligent import of existing policies, industry-standard document creation, and update features including the redline of changes and comments. The system shares policies with external systems through a PARDD-compliant Documents Templates and Requirements (DTR) interface and other APIs that provide access to policies in full form or deconstructed form to allow highly focused search capabilities.
PA Routing
Payers use this tool to configure rules that route prior authorization submissions to the correct department or line of business within their systems. Providers no longer need to interpret posted instructions from the payer or determine the correct destination, which prevents mistakenly sending submissions to the wrong department.
Automatic Authorization Rules
Support for complex rule creation and execution determines whether a submitted prior authorization should be automatically approved based on structured data. If the medical records for the requested prior authorization meet the required criteria, the authorization is approved automatically. If the criteria are not met, the submission is forwarded to a clinical reviewer. No automatic denials are performed. APIs are available for integration with Itiliti Health systems and other health plan systems as needed.
Clinical Decision Assistant
This product facilitates automated and manual review of prior authorization submissions. When a prior authorization is submitted, the medical record documents are converted into one long document with each original document represented as a section. The AI/ML search engine searches the document for evidence that the record demonstrates the member has met each criteria. Text that indicates a match is tagged with the criteria that it matches. The system can be configured to automatically approve a prior authorization based on the finding a match for the criteria or the system can present the outcome of the search to an approving user in a side-by-side view. The clinical reviewer can also search using tools to find and tag text that meets the criteria. This system is provided with multiple APIs for connections to payer workflow and UM systems.
PA Checkpoint™ is Your CRD Solution for the CMS Proposed Rule
This module facilitates both automated and assisted manual review of prior authorization submissions. When a prior authorization request is received, the AI/ML search engine examines the documentation for evidence that the member meets the required criteria. The system can be configured to either automatically approve a prior authorization based on matching the criteria or present the search results to a clinical reviewer in a searchable, side-by-side view for further analysis. The module includes multiple APIs for seamless integration with payer workflows and UM systems.