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- Health Insurance Claims
- Process
- Preauthorization decision
Preauthorization decision
A preauthorization is a request linked to a policy, organization and submitted revision. The reviewer reads the supporting evidence and records the insurer-confirmed decision. The request outcome and policy-level review decision remain separate. Match the operation key and receipt to the submitted request so the team can explain which version was authorized.
Step by step
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Record preauthorization Policy Operations Specialist
Policy Operations Specialist links the policy and organization and records the requested benefit and clinical evidence.
- Preserves policy, member and requested benefit context
- Updates Preauthorizations, Policies, Organizations
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Submit the request Policy Operations Specialist
The preparer freezes the version to be reviewed and moves the request from draft to submitted.
- Keeps the submitted revision and evidence
- Updates Preauthorizations, Record attachments
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Decide preauthorization Preauthorization Reviewer
Preauthorization Reviewer checks the evidence and source revision, then approves or rejects with a reason.
- Records independent decision and reason
- Updates Preauthorizations, Review decisions, Team members
ApprovalA person approves before the work moves on. -
Reconcile the outcome Finance Reconciler
Finance Reconciler uses the operation key and receipt effects to match the policy-level decision to the submitted request before completion.
- Checks operation key, scope and effect
- Updates Operation receipts, Preauthorizations, Review decisions
Who does what
Roles and permissions- Policy Operations Specialist
- Prepares the request.
- Preauthorization Reviewer
- Makes the independent decision.
- Finance Reconciler
- Checks operation evidence.
- Admin
- Manages staff identity and scope.
Set up Health Insurance Claims your way.
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