Extending the Prior Authorization request Microjourney
|Description||Identify and add extension points in the Prior Authorization request Microjourney|
|Version as of||8.5|
Extension points in the Prior Authorization Request
Pega Care Management offers the prior authorization (PA) request case for organizations to manage requests for inpatient, outpatient, pharmaceutical or referral requests. The PA case is comprehensive, however we recognize that organizations may have the need to extend the case to meet their specific needs. With this in mind, we have created out-of-the-box extension points and configurations points to support different organizational goals.
Use case examples
- In the Auto Authorization stage, customers can build their rules, based on the request type, for auto authorization of the request.
- An organization may want to check a member's policy for their eligibility for a specific procedure. This can be accomplished using
Check eligibilityin the
Auto Authstage of the case.
- There may be additional points of duplicate checking that an organization wants to add. These can be extended in the second stage of
Before you begin
- Create implementation layer by choosing the appropriate perspective (Payer/Provider)
- Review the case life cycle of authorization request
- Set the work groups and work queues as per your organizational needs
- For extending the program recommendation, supported program templates should be created using the BA portal
An example of extending the Authorization intake case could be to pass requests to a third party application. To do this, you can set the URL of the system to which you are extending the case type. You then set the URL of a third-party application and add the new fields to be passed from one application to the other.
- In the header of Dev Studio, search for
- Click the D_CreateAuthorizationCase data page.
- In the Data Sources section, click the gear icon next to the Request Data Transform field.
- To add more properties, on the Data Transform page, in the Target column, click the gear icon next to CreateAuthorizationRequestExtn.
- In the header of Dev Studio, search for
- On the Settings tab, enter the URL in the Value field for the location of Pega Care Management, or the third-party application.
- Click Save to save to your implementation layer.
- Restart the server so that the dynamic system setting takes effect.
Extending the correspondence templates
Below is the list of corresponding templates that are shipped with the application. These templates are picked based on the status of the PA case. Based on your organization needs update the relevant templates in the implementation layer. You can extend this functionality to consider other factors like: Auth request type in addition to status to pick the corresponding templates by extending the “GetCorrTemplate” decision table in the implementation layer
|AuthApproved_Reopen||For an approved PA through appeal|
|AuthApproved||For an approved PA|
|AuthDenied||For a denied PA|
|AuthDenied_Reopen||For a denied PA through appeal|
Case routing configurations
Below are the work queue configurations supported in PA. Configure the relevant work queues details in the PCM landing page
|Identifier/field in PCM landing page work baskets tab||Routing details|
|UM cases work queue||Case will be routed to this work queue in the clinical review stage|
|Request additional info work queue||In the internal guidelines review step of clinical review stage, if the reviewer indicates that the required documents are missing then the case will be routed to this work queue|
|Pending work queue||The PA will be routed to pend workbasket when the decision during clinical review /MD review is to pend the claim|
|MRC Coordinator||PA will be routed to MRC coordinator in case of denial. The MRC operator details should be configured in the field|
|Duplicate authorizations work queue||Duplicate PA cases will be routed to the configured work queue|
In the medical director review stage, the case will be routed to medical director whose skillset matches the required skills to review a claim. To configure skill-based routing refer the “Modifying the skill-level settings for the medical director review” topic in implementation guide
Configure SLAs for Prior Authorization processing
Based on the Level of service code the platform supports configuration of SLAs for PA case. Below are the details on the platform provided SLA’s for different “Level of service codes”. Based on your organization needs update the relevant SLA’s in the implementation layer. You can extend this functionality to consider other factors like: Auth request type to set the SLA’s on the case by extending the “AuthSLA” decision table.
|Level of service code||SLA Name|
Sample Auto-authorization rules are configured in the individual flows for distinct types of auth requests, extend below flows to configure your organization specific business rules.
|Request Type||Flow name|
Extending the program recommendation module
Program recommendation module provides the capability to refer a patient to a specific program based on the diagnosis. System checks if the patient is already enrolled to the program, if not, he/she will be referred to the configured program. System comes with sample rules for “Diabetes” program referral.
To trigger referrals for any other programs supported by your organization perform below steps
- Create code groups with relevant diagnosis codes
- Extend the RecommendProgram decision tree to configure the program recommendation based on the code groups
The user will be able to extend the prior authorization case type as needed by their organization.