Pend Resolution

This example refers to the process step configuration described in the Overview section to explain the influences of user access on the pend resolution process. Process step 'Duplication Check' has pend rule Potential Duplicate (with pend reason DUPE_CHECK.). Process step Medical Review has pend rule Missing Diagnostic Documentation (with pend reason DOC_MISSING_CHECK). For more details on these steps refer the section Duplicate Check and Medical Review.

There are four users that have Update rights on the View and Edit Authorization user interface page, but that have different Pend Resolution rights:

  • User 1 (first pend operator) has Pend Resolution rights for process step Duplication Check

  • User 2 (second pend operator) has Pend Resolution rights for process step Medical Review

  • User 3 (super user) has Pend Resolution rights for both process steps * User 4 (new user) has no Pend Resolution rights

An authorization is entered and submitted for processing. The authorization pends in process step Medical Review. Pend reason DOC_MISSING_CHECK is attached to the authorization and an authorization pend history record is created for the attached pend reason for the Pended status. The different users can perform the following actions in this Pended status:

  • The first pend operator cannot submit the authorization for further processing nor set the authorization to the Change status or Deny the authorization

  • The second pend operator can submit the authorization for further processing; he/she can also set the authorization to the Change status or Deny the authorization

  • The super user can submit the authorization for further processing; he/she can also set the authorization to the Change status or Deny the authorization

  • The new user cannot submit the authorization for further processing nor set the authorization to the Change status or Deny the authorization

If the authorization is submitted for further processing, the pend reason will be resolved (removed and resolved in the authorization pend history) and the authorization will be approved. If the authorization is set to the Change status, the pend reason will remain on the authorization and an authorization pend history record for the pend reason will be created for the Change status. In the Change status all (the above mentioned) users will be able to submit the authorization for reprocessing. What happens with the attached pend reason depends on which user submits the authorization.

If the second pend operator or the super user fixes the authorization being pended and submits the authorization, the pend reason will be resolved (removed and resolved in the authorization pend history) and the authorization will be reprocessed. It will no longer pend in process step Medical Review, because the error has been fixed, so it will eventually be approved. Note that if the user submits the authorization without fixing the error, the pend reason will still be resolved. If the 'Reattach?' indicator on the pend reason is checked the authorization will again be pended in process step Medical Review; else it will not pend again and it will be approved.

If the first pend operator or the new user fixes the error that resulted in the authorization being pended and submits the authorization, the pend reason will not be resolved, but the authorization will reprocessed. Because the pend reason is not resolved, the authorization will again pend in process step Medical Review (regardless of the 'Reattach?' indicator), where the second pend operator or the super user needs to approve the fixes and resolve the pend. Note that the same happens even if the first pend operator or the new user submits the authorization without fixing the error.

Now let’s say the first pend operator or the new user edits the authorization to fix the error, but the new edits now make the authorization request similar to an existing request. The user submits the authorization: the pend reason will not be resolved, the authorization will now be reprocessed.

Now, because of the newly introduced attributes, the authorization pends in process step Duplication Check. Pend reason DUPE_CHECK is attached to the authorization and an authorization pend history record is created for the attached pend reason for this Pended status. Note that pend reason DOC_MISSING_CHECK is still attached to the authorization; there is no authorization pend history record created for that pend reason for the new Pended status. The different users can perform the following actions in this Pended status:

  • The first pend operator can submit the authorization for further processing; he/she can also set the authorization to the Change status or Deny the authorization

  • The second pend operator cannot submit the authorization for further processing nor set the authorization to the Change status or Deny the authorization

  • The super user can submit the authorization for further processing; he/she can also set the authorization to the Change status or Deny the authorization

  • The new user cannot submit the authorization for further processing nor set the authorization to the Change status or Deny the authorization

If the authorization is submitted for further processing, only pend reason DUPE_CHECK will be resolved; pend reason DOC_MISSING_CHECK will remain on the authorization. Note that this also applies if the super user, that has Pend Resolution rights for process step Medical Review, submits the authorization. If the authorization is set to the Change status, both pend reasons will remain on the authorization and an authorization pend history record for both pend reasons will be created for the Change status. What happens with the pend reasons when the authorization is again submitted depends on which user submits the authorization:

  • First pend operator: only pend reason DUPE_CHECK is resolved

  • Second pend operator: only pend reason DOC_MISSING_CHECK is resolved

  • Super user: both pend reasons are resolved

  • New user: no pend reasons are resolved