Overview

The authorization processing overview is shown in the image below.

Process Authorization

When an authorization is submitted for processing, the authorization status is set to 'In Process'. The authorization status history, authorization pend reasons, authorization pend reason history and authorization messages are also updated. This is described in detail in the subsequent section Submit Authorization of the Operations Guide.

The next step is the application checks for enrollment data:

  • If enrollment data is present, and the Keep enrollment information option is selected, the system skips enrollment response retrieval, regardless of timer settings or expiration.

  • If enrollment data is present and the Keep enrollment information option is cleared, the system checks whether the data has expired. It compares the elapsed time since the data was received with the cache expiry time set in the ohi.processing.enrollment.cacheexpiry property. For more information on setting a property, see Application Properties.

  • If no enrollment data exists and the Keep enrollment information option is selected, the system returns the fatal error AUT-FL-ENRO-001: No enrollment data found and enrollment callout is disabled.

  • If no enrollment data is available, or the existing data has expired, the system either generates the enrollment response internally through the dynamic logic function configured by the ohi.enrollment.dynamiclogic.code property or retrieves it from an external system through the Enrollment Response Integration Point when that property is not set. See Enrollment Response Integration Point.

The enrollment details are stored in Oracle Health Insurance Authorizations as described in the section Enrollment Callout.

After enrollment information has been reused, generated, or retrieved, the next step in the flow is the evaluation of process steps.

More detail on the processing of the process steps and rules is described in the section Process Rules of the Operations Guide.

After execution of all the process rules, the system executes the final step in processing Finalize. During this step the system determines if the authorization is 'Approved' or 'Denied'. An 'Approved' or 'Denied' authorization can be 'Un-finalized' if required. Un-finalizing an authorization creates a new version and makes it possible to modify the authorization and reprocess it.

Authorization Statuses

The status of an authorization reflects the authorization’s position in the flow. An authorization can have only one status at a time.

The following authorization statuses exist:

Table 1. Authorization Statuses
Status Description

Entry

The authorization has been entered and saved, but not yet submitted

In Process

The authorization is being processed

Pended

The authorization attains this status when it is pends as a result of a configured pend rule. Processing is suspended

Changed

An authorization that was submitted earlier can now be edited and resubmitted for processing

Approved

The authorized is approved

Denied

The authorization is denied

The authorization status flow is shown in the picture below

Authorization Status Flow