UC-424
Medical Policy Criteria & Turnaround Clock
Reads each request and attachments, lines evidence up against each medical policy criterion, and hands a pack to the clinical reviewer.
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The Challenge
Most requests arrive incomplete, so nurses spend the turnaround clock chasing providers for one missing note. Criteria, member history and clinical attachments sit in three systems with different identifiers.
How It Works
- Reads the authorisation request, clinical attachments, claims history and the criteria set.
- Maps each medical policy criterion to evidence in the file and dates the turnaround clock.
- Puts the criterion pack and the chase letter on the reviewer's queue the same day it lands.
What It Removes
- Chasing providers for a note already in the file
- Manual reading of attachments for criterion evidence
- Re-keying request details into the utilisation system
Input Data RequirementsAuthorisation requests and attachments, published medical policy criteria, member eligibility and claims history, provider contracts, clock records
Output FormatCriterion-by-criterion evidence pack, drafted missing-document request to the provider, turnaround clock view by queue and by reviewer
“Requests stall on one missing page, and we burn the turnaround clock working out which page it is”