Extending the Prior Authorization request Microjourney

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Extending the Prior Authorization request Microjourney

Description Identify and add extension points in the Prior Authorization request Microjourney
Version as of 8.5
Application Pega Care Management
Capability/Industry Area Healthcare and Life Sciences



Extension points in the Prior Authorization Request[edit]

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.

The highlighted steps have out-of-the-box extension points.

Use case examples[edit]

  • 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 eligibility in the Auto Auth stage 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 CheckDuplicates.

Before you begin[edit]

  • 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

Process[edit]

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.

  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, on the Data Transform page, in the Target column, click the gear icon next to CreateAuthorizationRequestExtn.
  5. In the header of Dev Studio, search for CareManagementinstance.
  6. On 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 to save to your implementation layer.
  8. Restart the server so that the dynamic system setting takes effect.

Extending the correspondence templates[edit]

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

Correspondance rule Condition
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[edit]

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[edit]

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
E AuthElectiveSLA
U AuthUrgencySLA

Extending the auto authorization[edit]

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
Inpatient AdmissionDecision
Outpatient HealthServicesDecision
Referral SpecialtyCareDecision
Pharmacy DrugReviewDecision

Extending the program recommendation module[edit]

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

Results[edit]

The user will be able to extend the prior authorization case type as needed by their organization.