As care management and health IT continue their mutual evolution, payer organizations must negotiate complex requirements for processing authorization requests from their provider networks. Not only do they need to secure the clinical information to substantiate the medical appropriateness of those requests, but they may also need to convey authorization decisions to Third-Party Administrators (TPAs) or other claims processing systems. At MCG Health, we support these complex authorization processes by allowing payers to substantiate their medical determinations against evidence-based guidelines and then align those decisions with claims disbursements using EDI X12 standards.
Claim Link, a new software enhancement to our existing Cite AutoAuth solution, allows payers to transmit their authorization decisions to TPAs, external claims processing organizations, or even home-grown medical management and claims systems. After the clinical decision has been made to approve, pend, or deny a request, Claim Link supports its transmission with X12 278 file standards on a HIPAA compliant platform and allows the payer to track the status of the authorization. These new capabilities allow AutoAuth customers licensing Claim Link to efficiently exchange transactions and further support complex requirements for processing authorizations.
What is EDI X12?
EDI X12 (Electronic Data Interchange) uses ASC X12 standards and is primarily used to exchange specific data between two or more entities using a common format. EDI X12 is governed by standards released by ASC X12 (or the Accredited Standards Committee) and is an important component of the HIPAA Transactions and Code Sets Rule.
Last year, a record number of MCG payer clients leveraged AutoAuth to align MCG care guidelines and their medical policies to support medical necessity documentation during the authorization request process. AutoAuth shares this information (in a secure fashion) to care providers as they enter prior authorization requests via an online portal. AutoAuth allows the providers to document their decision-making and include the clinical documentation required for the payer or health plan to evaluate the medical necessity of an authorization.
In addition, using AutoAuth, payers can write rules to approve, pend, or deny multiple authorization scenarios. For example, these rules include the ability to:
- Automatically display any notifications that prior authorization is not required to the provider
- Deny any potentially non-covered benefits
- Approve gold-carded providers
- Pend and request additional clinical information
- Approve when MCG care guidelines or medical policy indications are met
By collecting clinical appropriateness against evidence-based guidelines and deploying payer-defined automated rules, health plans and payer organizations can increase operational efficiency by decreasing the number of authorization requests needing manual review. These capabilities also increase provider satisfaction by allowing real-time approvals (when appropriate) and reduce overall turnaround times for authorization requests.
MCG continues to create innovative solutions to increase efficiency by streamlining authorization processing with medical necessity determinations. This year, MCG will release additional solutions and software updates to enable payers to accept authorization responses from multiple sources:
- Cite for Collaborative Care will create a bridge between MCG provider clients who use Indicia, our provider-side software, to submit inpatient authorization requests directly to payers. The provider’s EMR will be integrated with Indicia in a way which will allow them to select the clinical indications and submit the authorization. Through Collaborative Care this will be received by payer client using Cite CareWebQI and the appropriate response will be sent accordingly. Learn more about Cite for Collaborative Care by watching the on-demand webinar.
- Indicia for Admission Documentation will leverage medical record data matched against MCG care guidelines to provide level-of-care recommendations in real-time and within the provider’s workflow of the existing EMR platform. Learn more about Indicia for Admission Documentation by watching the on-demand webinar.
MCG will continue to listen to our customers’ needs and develop solutions which foster innovation and efficiency within the health care system. We look forward to collaborating with organizations sharing like-minded goals. If you’d like to see a demo of Cite AutoAuth with Claim Link, or any of our other solutions, submit a request for an MCG representative to contact you. If you are an EMR, medical management, or population health software vendor seeking to integrate MCG solutions or content, please contact us.
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