INSURANCE VERIFICATION AND AUTHORIZATION PROCESS

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[ ] Fetch Patient Demographics: Retrieve patient information from the Patient Data Model to verify identity and coverage details.
[ ] Retrieve Insurance Policy Details: Fetch active insurance plan details and coverage limits from the Policy Data Model.
[ ] Create Verification Request: Generate a new 'Verification Request' entry in the Authorization Data Model to track the start of the process.
[ ] Perform Eligibility Check: Assign a task to the Billing Specialist to verify if the insurance policy is active and covers the specific procedure.
[ ] Calculate Co-pay and Deductible: Calculate the patient's out-of-pocket responsibility based on the retrieved deductible and co-insurance percentages.
[ ] Update Coverage Status: Update the Verification Request entry with the results of the eligibility check (Active/Inactive).
[ ] Clinical Documentation Review: Assign a task to the Medical Coder to ensure the clinical notes support the necessity of the requested procedure.
[ ] Get Procedure Codes: Retrieve the specific CPT/HCPCS codes requested for authorization from the Service Request Data Model.
[ ] Create Prior Authorization Submission: Create a new entry in the 'Auth Submissions' model to track the formal request sent to the payer.
[ ] Assign a task to the Authorization Coordinator to call the insurance company if no response is received within 48 hours.: Assign a task to the Authorization Coordinator to follow up with the payer if no response is received within the SLA.
[ ] Log Payer Response: Update the Authorization entry with the decision (Approved, Denied, or Pending) and the Auth Reference Number.
[ ] Calculate Total Estimated Revenue: Aggregate the estimated costs of all approved procedures in the current verification batch.
[ ] Notify Patient of Authorization Status: Send an automated email to the patient informing them whether their procedure has been approved or if more information is needed.
[ ] Alert Billing Department: Send an SMS notification to the Billing Manager when a high-value authorization is denied.
[ ] Generate Weekly Auth Denial Report: Generate a report summarizing all denied authorizations, reasons for denial, and payer trends for the week.
[ ] Cleanup Duplicate Requests: Delete any duplicate verification entries created by mistake during the intake process.

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