Payer Configurations

As part of the integration process, a series of configurations must be applied. Some of these may be optional. The configurations include:

• Definition of authorization types (Medications, Labs, Imaging, etc.).
• Medical Appropriateness:
  • Review, configuration, and approve the medical appropriateness matrix by the payer’s team.
  • Coding of diagnoses and CPT codes.
• Operational Rules:
  • Authorization rules (validity, recurrence, etc.).
  • Anti-fraud and security rules (authorization limits, authorization duplication, etc.).
  • Registration of internal or external providers (Doctors, Pharmacies, Labs, Clinics).
  • Integration/communication methods with patients/providers (email, SMS, others).
  • Internal process rules for automation and manual review (manual review, automatic, etc.).
  • Internal process rules for managing payment types (Reimbursement or Direct Payment).
  • Customize authorization communications (logos, graphic schemes, approval/rejection messages, notes for insured members, etc.).
  • Rules for controlling authorization overages.