Intelligent Prior Authorization 26.04

The features below are available with this release.

Highlights

Support is added for multiple coverages in a prior authorization.
An Prior Authorization agent now is integrated with Oracle Health Patient Administration with a patient-centric prior authorization view.

Solution Change Details

Solution Change	Description and UI Impact	Reference Materials	Validation Guidelines	Implementation and Maintenance Impact
Prior Authorization UI Enhancements - OHPRI-2112	Prior Authorization is enhanced to better meet the requirements of HTI-4, add support for multiple coverages in a prior authorization, further integrate with Oracle Health Patient Administration and Patient Portal, and expand CMS integration for providers impacted by the Wiser program. UI Impact Workflow (Automatic) A Medical Necessity badge is displayed based on Centers for Medicare & Medicare Services (CMS) National Coverage Determination (NCD) and Local Coverage Determination (LCD) guidelines to indicate the that a procedure for prior authorization is likely or unlikely to meet CMS's medical necessity guidelines. When the Prior Authorization AI Agent completes the prior authorization questionnaire, or attaches clinical documentation, an explanation and link to the document references is available. When obtaining prior authorization, you can add a billing authorization note to the patient chart for evidence of prior authorization being received from the payer.	See Intelligent Prior Authorization Provider User Guide for more information.	Verify that you can successfully complete the workflows in the Reference Materials.	Implementation Impact: None Maintenance Impact: None
Payer Connectivity - OHPRI-2946	Prior authorization capabilities now are expanded to improve collaboration between payers and providers. Enhanced Automation: Improved EDI 278/275 workflows with automated routing and response handling. Payer Hub Improvements: Easier credential management, refined routing logic, and more flexible endpoint configuration. Broader Integration: Improve visibility into prior authorizations within registration and scheduling workflows through integration with PAS and Millennium systems. FHIR API Support: Standards-based connectivity with compliant payers using DaVinci CRD, DTR, and PAS APIs. AI-Powered Authorization: A Prior Authorization AI agent interprets payer requirements using patient chart data, helping generate more accurate responses. Expanded Routing Capabilities: Provider-specific routing supports third-party vendors, including Glidian. Centralized Payer Directory: A scalable directory streamlines endpoint management and routing logic. UI Impact: None	None	No validation testing is provided because the solution change contains updates not visible to users. As part of your regression testing, ensure that your system is working as expected.	Implementation Impact: None Maintenance Impact: None

Solution Change

Description and UI Impact

Reference Materials

Validation Guidelines

Implementation and Maintenance Impact

Prior Authorization UI Enhancements - OHPRI-2112

Prior Authorization is enhanced to better meet the requirements of HTI-4, add support for multiple coverages in a prior authorization, further integrate with Oracle Health Patient Administration and Patient Portal, and expand CMS integration for providers impacted by the Wiser program.

UI Impact

Workflow (Automatic)

A Medical Necessity badge is displayed based on Centers for Medicare & Medicare Services (CMS) National Coverage Determination (NCD) and Local Coverage Determination (LCD) guidelines to indicate the that a procedure for prior authorization is likely or unlikely to meet CMS's medical necessity guidelines.
When the Prior Authorization AI Agent completes the prior authorization questionnaire, or attaches clinical documentation, an explanation and link to the document references is available.
When obtaining prior authorization, you can add a billing authorization note to the patient chart for evidence of prior authorization being received from the payer.

See Intelligent Prior Authorization Provider User Guide for more information.

Verify that you can successfully complete the workflows in the Reference Materials.

Implementation Impact:

None

Maintenance Impact:

None

Payer Connectivity - OHPRI-2946

Prior authorization capabilities now are expanded to improve collaboration between payers and providers.

Enhanced Automation: Improved EDI 278/275 workflows with automated routing and response handling.
Payer Hub Improvements: Easier credential management, refined routing logic, and more flexible endpoint configuration.
Broader Integration: Improve visibility into prior authorizations within registration and scheduling workflows through integration with PAS and Millennium systems.
FHIR API Support: Standards-based connectivity with compliant payers using DaVinci CRD, DTR, and PAS APIs.
AI-Powered Authorization: A Prior Authorization AI agent interprets payer requirements using patient chart data, helping generate more accurate responses.
Expanded Routing Capabilities: Provider-specific routing supports third-party vendors, including Glidian.
Centralized Payer Directory: A scalable directory streamlines endpoint management and routing logic.

UI Impact:

None

No validation testing is provided because the solution change contains updates not visible to users. As part of your regression testing, ensure that your system is working as expected.

Implementation Impact:

None

Maintenance Impact:

None

Parent topic: Intelligent Prior Authorization Solution Change Details