Prior Authorization, Claims Processing Rules Engines, and Call Center Services

What is Prior Authorization?
Prospective review (also referred to as prior plan approval, prior authorization, or certification). It is the process by which certain medical services or medications are reviewed against healthcare management guidelines prior to the services being performed. Reviews are done to confirm the following information:

• Member eligibility
• Benefit coverage
• Identification of co-morbidities and other problems requiring specific discharge needs
• Identification of circumstances that may indicate a referral to Concurrent Review, Discharge Services, Case Management, or Member Health Partnerships

Prithvi offers expertise in providing Prior Authorization solutions through dedicated software framework architecture and technology expertise. It consists of the latest Microsoft .NET classes and frameworks.

Our Prior Authorization solutions ensure:

• An interface between the health care providers and the Prior Authorization departments for a fast and secure authorization service
  
• The system also brings the added advantage of storing and retrieving health plan  information for responding to the authorization request

Part of the solutions framework is the Claims Processing - Rules Engine that our technology architects have designed that ensures compliance to the rules set by Health Plan providers or Government Agencies for Prescription Drugs, Radiology Services, Lab Procedures, Specialist Services and Durable Medical Equipment services.

Prithvi also prides itself in providing end-to-end call center consulting services in the areas of Prior Authorization software solutions framework and training employees of Prior Authorization departments consisting of CSR’s, Registered Pharmacists, Supervisors and Medical Directors.