Understanding Prior Authorization
A prior authorization is an approval from a health plan that is required before specialized services or medications may be provided, to ensure they can be paid for.
There are many points in healthcare where digital conversations and reconciliations must occur for tracking and accountability. For example, in a previous blog we discussed how HL7 ADT messages (HL7v2) are used to communicate patient care status between facilities. We also talked about how facility-to-facility interoperability is growing.
Prior authorization also goes by the names “prior auth“, “preauthorization“, “preapproval“, and “precertification“.
Prior Authorization Flowchart
Some extra notes:
In a life-threatening emergency, hospitals are not allowed to deny treatment to patients, regardless of their insurance or financial situation.
In non life-threatening emergency, the entity footing the bill must be determined beforehand. This may be the government via the insurer (Medicare, Medicaid, commercial), the insurer if it matches their policy, or the patient themselves if neither the government or the insurer agree to do so. There is both an urgent (72 hour window) and non-urgent (within one week) version of non-emergency requests.
If no entity is willing to pay for treatment, the bill is passed on to the patient should they still like to receive the treatment.
If the patient has already been treated, but no-one agrees to pay, the patient must pay the bill out of pocket. If the patient is unable to pay, the hospital ultimately foots the bill to maintain operations.
Explanation of Benefits (EOB)
Explanation of benefits is a legal document that describes what a patient can be approved for. Here is an example of prior authorization guidelines of the required evidence for a patient to be approved for a hearing aid. It includes definitions and codes that, if document by a practitioner, will result in a hearing aid to be paid for for a patient.
How Fast Is It?
In the old days, prior authorization would require a phone call. Historically it still may have taken up to 30 days depending on the looseness of definitions, documentation, and the need for legal opinions. However it is more than possible for prior authorizations to be instantaneously approved.
It is not however, common or likely for an instant denial. This is because evidence for paying out, if found, should immediately be captured. If it is not instantly found, it may require a human to make sure the evidence is not located in a medical chart in an unstructured section. This is where Tenasol comes in. Tenasol is able to detect approval evidence faster, and report them to reviewers who may not otherwise see them to expedite prior authorizations. In some cases, Tenasol is capable of instant approvals if they are found in structured sections of documents.
Health Data, Technology, and Interoperability: Trusted Exchange Framework and Common Agreement (HTI-2)
HTI-2 is a recent policy change that expedites the time that a prior authorization takes:
urgent requests are still 72 hours
non-urgent requests are reduced to 7 days from 14 days (with extensions)
FHIR API standards are outlined for auto-approvals in cases that can happen within seconds.
These changes were made to shift towards faster patient treatment, to encourage technological progression, and to reduce payer float. The auto approvals are nearly instantaneous and appear like this:
Automatic Prior Authorization (Blue)
For this to work in real-time:
[REQUIRED] the practitioner must have FHIR (HL7v4) adopted for external communication
[REQUIRED] the insurer (payer) must have FHIR (HL7v4) adopted for external communication
[REQUIRED] the practitioner and the insurer must be integrated such that they can exchange information in an encrypted fashion.
[OPTIONAL] the insurer OR the practitioner facility contact the pharmacy (if the pharmacy has FHIR integration with one of them) to fill and dispense the medication to the patient.
This interesting also opens the possibility for a practitioner to be able to see the treatments or medicines that a patient can be approved for at the point of care.
Tenasol and Prior Authorization NLP
Tenasol is capable of detecting the information inside of a patients medical records using NLP to see if it contains evidence that allows the patient to be approved. This includes both structured and unstructured fields.
This step occurs after the insurer receives the information, should the insurer have access to both the patient medical records and required evidence for the treatment or medication at hand.
Where Tenasol comes in
It is not uncommon for this evidence to be in a medical record that the insurer has, as opposed to simply stored in a database already.
Tenasol permits performing this data on any structured data, but is also capable of quickly extracting information for a reviewer to immediately locate for the following medical record formats:
PDF/TIFF/TIF/JPG/JPEG/PNG unstructured data
RTF - rich text format
…and others
This information is then output via:
API
highlighted PDF describing evidence
or custom alternative output format
Conclusion
Prior authorization serves as a crucial checkpoint in modern healthcare, ensuring that treatments and medications are both medically justified and financially accounted for. Historically, this process was often a bottleneck, taking days or even weeks to complete due to manual reviews and fragmented communication between providers and insurers. However, the landscape is rapidly changing with advancements in interoperability standards like FHIR and the adoption of automation technologies.
Tenasol exemplifies how automation is transforming prior authorization. By leveraging intelligent systems capable of analyzing unstructured medical records, Tenasol bridges the gap between structured evidence and payer requirements. This not only accelerates approvals but also reduces the burden on providers and ensures patients receive timely care.
As healthcare continues to embrace digital transformation, automation tools and standardized communication protocols will play an increasingly vital role. Together, these innovations pave the way for a system where prior authorization becomes less of a hurdle and more of a seamless step in delivering quality care to patients.
Let us know if you would be interested in seeing a demo of these services by contact our sales team at sales@tenasol.com