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Authorization Request

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Updated on March 18, 2021

A prior authorization is an approval of medical services by an insurance company, usually prior to services being rendered. Although the procedure might take place in the hospital, the responsibility lies with the physician's office to obtain the prior authorization. Organizations use prior authorization for management of high cost, high utilization, or other services that require monitoring. Frequently, prior authorization has been used to control medical costs that are experienced by a health plan or provider organization. Prospective is offered for Inpatient, Outpatient, Referral, and Pharmacy management.

You can create authorizations in a patient profile by clicking ActionsNewAuthorization request.

You can search for an authorization request in the Pega Care Management application. In the CM Care Manager portal, click Tools, and then click the Authorization tab.

You can search authorization cases by using the following criteria:

  • Member, provider, or facility
  • Request from and to dates
  • Procedure or diagnosis codes

For more information about authorization requests, see Authorization management in the Pega Care Management Business Use Case Guide on the Pega Care Management product page.

Design Patterns: For more information, see Extending the Prior Authorization request Microjourney.

The following list describes items that are related to the Authorization Request Microjourney:

  • Saving the D-GetAuthorizationDetailsforMember rule
  • Data model
  • Extending the Authorization Intake case type
  • Configuring printers for bulk printing of authorization reviews
  • Extending the print case summaries

Saving the D_GetAuthorizationDetailsForMember rule

Because look-up data pages do not support dynamic class referencing, you need to save the D_GetAuthorizationDetailsForMember rule in the appropriate implementation-layer class context so that the data page can fetch the implementation-layer specific data. Otherwise, the look-up fails and the data page does not return any data.

Data model

In App Studio, you can view the data model for Prior Authorization Request in Case Types.

Click the Data model tab on the Prior authorization request page.

Extending the Authorization Intake case type

You extend the Authorization Intake case type to pass requests to the Pega Care Management application or a third-party application.

To do this, you can set the URL of the system to which you are extending the case type. For example, you set the URL of the Pega Care Management application or a third-party application. You can also add new fields to be passed from one application to the other.
  1. In the header of Dev Studio, search for D_CreateAuthorizationCase.   
  2. Click the D_CreateAuthorizationCase data page.
  3. In the Data Sources section, click the gear icon next to the Request Data Transform field.
  4. To add more properties, in the Data Transform page, in the Target column, click the gear icon next to CreateAuthorizationRequestExtn.
    For more information, see data transforms.
  5. In the header of Dev Studio, enter and search for CareManagementinstance.
  6. In the Settings tab, enter the URL in the Value field for the location of Pega Care Management or the third-party application.
  7. Click Save and save it to your implementation layer.
  8. Restart the server so that the dynamic system setting takes effect.

Configuring printers for bulk printing of authorization reviews

With the bulk printing of authorization reviews feature, you can move from printing single documents to printing multiple reviews at a time. Then care managers can print or review cases for subsets of authorization reviews. For example, they need to print legal reviews, appeal reviews, diagnosis reviews, scheduled regulatory and accrediting audits, or a random audit by date, as part of audit activities.

For more information, see Bulk print in the Pega Care Management Business Use Case Guide on the Pega Care Management product page.

Before you begin: You need to plan with the client for the number of printers that will be configured. The printers must be on the same server where your care management application resides.
  1. Determine the number of printers that will be available for bulk printing of authorizations.
  2. Configure the printers, and verify that the configured printers are displayed in the Print Options dialog box that appears when you are bulk uploading authorization reviews.

Extending the print case summaries

You can extend the print case summaries to include additional information for printing.

  1. In the navigation pane of Dev Studio, click RecordsUser InterfaceHarness.
  2. To find the Print harness, on the Harness page, filter the Purpose column with the PrintMemberDetails harness name.
  3. Click the record.
  4. Update the Print harness with the additional information that you want printed.
  5. Click the Scripts & styles tab.
  6. In the Scripts section, insert two rows.
    1. In the first row, enter harness_print in the Name column. Select js as the type.
    2. In the second row, enter harness_print_post_activity in the Name column. Select js as the type.
  7. To customize the printing behavior, save the PrintMemberDetails activity to your ruleset and modify the activity as needed.
  8. Click Save.
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