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Healthcare Authorizations

Verify prior authorization requirements and medical necessity upfront to ensure procedures are approved prior to service.

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Prior Authorization

Confirm medical prior authorization requirements in real time before service to avoid denials and reduce administrative costs. With our solution, you can utilize a comprehensive, up-to-date rules library comprised of more than 16,000 medical codes to help:

  • Streamline and automate the screening of prior authorization requirements
  • Standardize workflows to optimize staff efficiencies
  • Prioritize procedures that require follow-up phone calls to payers
  • Access both payer-published rules with provider in-house custom rules
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Medical Necessity

Accurately determine medical necessity prior to service to better inform patients, improve medical documentation and reduce financial risk.

  • Validate procedure codes against Medicare medical necessity rules and determine diagnoses that pass or fail coverage rules.
  • Generate Advanced Beneficiary Notice (ABN) when needed for patient signature
  • Provide an accurate, credible estimate of covered and non-covered services when combined with our Patient Payment Estimation solution
  • Advise patients on their financial responsibility for care

These authorization solutions can be combined with our Patient Payment Estimation solution for both healthcare providers and healthcare partners.

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"Combining medical necessity compliance checks with a contracts-based patient payment estimator and propensity to pay information empowers our staff with the tools necessary to educate patients on their payment options. It also reduces our financial risk for claim denials post service. We expect this to have a significant impact on our point-of-service collections and net revenue as we’ll know earlier in the process how much the patient owes, and what procedures will be covered by their insurance company."

TransUnion Healthcare client

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