The SCE can identify when authorizations are required and then to apply them to the claim. Authorizations can be limited to a maximum dollar amount or limit on the number of services. The SCE provides the module Process authorization (SPA) to perform these functions.

During the claims adjudication process, claims are evaluated to determine whether:

• Services provided to the member require referrals or authorizations.
• An active referral or authorization exists for the member according to the health plan’s policies and rules.

During the execution of the process authorization module, SCE matches claim information with referral and authorization requirements, and then determines whether a claim or claim line complies with those requirements.

Actual authorization and referral instances are created in an external utilization management application, such as Pega’s Care Management Application (PCM) and mapped to the authorization data model in the healthcare foundation (PFHC) for use. The comparison of authorization data elements to claim line data elements is accomplished using Elasticsearch functionality, which is integrated into the process authorization module. In addition, the authorization processing workflow accommodates a robust approach to processing exact matching and non-exact matching authorizations. Fall-out for various authorization matching scenarios allows the user to resolve single and multiple non-exact authorization matches using SCE’s guided event resolution.

The SCE uses two methods to identify if an authorization is required for the claim service. The first is viewing the authorization requirements on the benefit. If the benefit matched to the claim requires an authorization, the authorization fields in the benefit screen on the claim will be populated and show the type of authorization required.

The second method is to use the IsAuthorizationRequired decision table for determining whether an auth is required. This decision table allows authorizations to be required for specific procedure codes billed on the claim line. This table can easily be extended to add other criteria as necessary. The type of authorization is returned in the actions (Authorization or Referral).

The SCE uses Elasticsearch to match the authorization to the claim based on the type of authorization required. Each claim type and authorization type utilize different queries to match the claim based on the types of data needed for the query.

The Elasticsearch (ES) process uses 1 of 5 discrete out-of-the-box queries when fetching matching authorization candidates. As indicated above, SCE selects the ES query to run based on the information returned in the RequestedAuthType decision table. The 5 ES queries are: Inpatient Facility, Outpatient Facility, Professional, Referral, and Dental. All the queries are extensible, allowing the user maximum flexibility in creating auth matching scenarios that will accommodate specific business needs. The queries are designed to parse the auth instance data elements, then match those data elements to the claim line data elements to determine whether those auth instances are an exact match to the claim line, a non-exact match, or no match, based on the auth matching criteria.

The SCE provides some extra configuration for the queries to broaden the search, through the Authorization match days field. This enables the SCE to extend the dates of service on the claim plus and minus the number of days to help ensure a match can be made against the begin and end dates on the authorization. The minimum and maximum search results are used to tune the performance and avoid too many authorizations being returned.

The other configuration that drives the matching is whether the SCE will automatically select single or partially matched authorizations for adjudication. The SCE controls this configuration through the Automatic non exact authorization resolution option. When this is set to On, the SCE will automatically assign single or multiple partially matched authorizations to the claim. If this is off, the claim will set an event code for review and selection of the auth(s) by an examiner.

Following the execution of the query, SCE determines through a series of steps whether: one or multiple exact matching authorizations were found, one or multiple non-exact matching authorizations were found, or no matching auths were found. SCE resolves each condition according to the following workflow.

If multiple exact matching auths are found, SCE parses and rank-orders each from the query according to its certification date (oldest first).

If the automatic non-exact match configuration is set to Off, event codes will be set on the claim for manual authorization selection.

At the end of the matching workflow, when all the authorizations for processing have been identified, the SCE retrieves all the associated accumulators to support the processing of the authorizations.

The SCE also packages a configuration for specialized processing with some sample event codes. This process provides a configuration where similar procedure codes are billed on the claim, but only one of the codes is associated with the authorization. In this instance, event codes will be associated with the claim for manual authorization resolution. This table can be extended, and new event codes created as appropriate.

In the table above event codes SPA-0047 or SPA-0048 are set on the claim based on the configuration of the procedure codes.

Once the authorizations are matched (manually or automatically) and available in a list for processing, the steps detailed in the following graphic are applied. The workflow includes validating authorizations, applying auth units (including partial auth units), and updating authorization accumulators. The final step is to assign the related claims section for all claims associated with the same accumulator.

SCE validates each authorization by determining whether the authorization is active (A1- Certified in Total), or inactive (A3-Not Certified, or A4-Pended). If the authorization is not active, the claim line is pended for manual review. If active, SCE then determines whether there are enough authorization units available to accommodate the claim line requested units (based on the accumulator returned in the previous step). If no units are available from the existing accumulator, the claim line pends. If the authorization is new and requires an accumulator, a new accumulator is created.

Once SCE validates that an authorization is active, and that authorization units are available, SCE then determines whether the units requested on the claim line are greater than the units available on the authorization. If the claim line units are equal to or less than the authorization units, SCE processes the approved units and updates the authorization accumulator. The authorized units are then applied to the benefit, and the accumulator is updated according to the processed transaction before moving to the next step in the adjudication process. In this situation, the approved units will match the units of service billed on the line.

If the requested claim line units are greater than the available units on the authorization, SCE then executes a “cutback” by approving the claim line units up to the number of available auth units and adjusting the claim line units based on the difference between the billed claim line units and the approved units from the auth. The non-approved units are adjusted on the claim line to ensure unit balancing. When the claim is adjusted, adjustment reason code 198 is applied to the adjustment section of the claim line:

In addition, the updated accumulator is displayed, which was exhausted during the processing of this claim line.

When a claim line is processed against an exhausted accumulator, the claim line is suspended. As there are no available units in this authorization (which was exhausted in the previous example), an event code SPA-0021 is triggered and the claim line is suspended.

In the instance that the claim line includes both authorization limits and benefit limits and a benefit limit has been met through a previous adjuciation step, the authorization will take precedence and remove any adjustments associated with the benefit limit. Action code BENAU will be applied to the claim for review.

Note: the application of this action code occurs both in the benefit limit processing and the authorization processing, depending upon the order of modules being executed.

Once the authorization has been matched and used in the adjudication, the Adjudicated authorization section of the claim line screen is updated with a link to the matched authorization. The prior authorization section is used to show any prior authorization numbers that were submitted on the claim.

Selecting the hyperlink will open the authorization details screen, which contains the request as well as appropriate provider or patient details.

The final screen for the matched authorization is the related claims screen. This is accessed through the related claim details link in the claim summary tile. The related claims screen shows a summary of the authorization, along with the claims that have been processed with the same authorization.

The authorization sets a series of event codes during the processing. The following table provides the list of event codes applied to the SCE.

When multiple non-exact matched authorizations are identified, and the system setting for Automatic non exact authorization resolution is set to False, the SCE provides a guided flow to manually select the authorizations for processing.

The guided event resolution flow presents the list of authorizations identified through the non-exact matching process. The examiner can select the Auth. ID to display the full authorization information for review. If one or more authorizations can be applied to the claim, the examiner can return these authorizations by selecting Return authorization.

The examiner can then select the appropriate authorizations to adjudicate on the claim and select apply.

Select appropriate authorization and then Apply. The authorization will then be selected with the claim for adjudication and visible in the adjudicated authorization link.

When the claim is re-adjudicated, these authorizations will be applied, and the audit trail will identify that the event code was resolved by selecting authorizations.