Authorization Queue Improvements Copied

The logic in the Ins. Auth/Fin. Counseling queue has been enhanced to respond more appropriately to interface updates to a patient’s insurance, such as the addition of a new policy or removal or change to an existing policy.

We realize that the logic used in this area is complex and is further complicated by the fact that for a given patient, multiple insurers might be valid at the same time, and that the insurer(s) may change in the middle of a regimen.

The goal of this revised functionality, as shown below, is to archive/invalidate prior insurance approvals more appropriately. We plan to continue to refine the rules and logic used as we learn more about the most common use cases.

NOTE: The diagram below does not cover all scenarios.

In this release, the following general principals were applied:

1. Changes to existing insurance (the insurance matches on patient name, insurance ID, and policy number):
   1. If the update sent does not include an expiration date, the system will not archive prior approvals.
   2. If the update sent includes a future expiration date, the system will archive prior approvals where the treatment date is after the updated insurance expiration date.
   3. If the update sent includes a past expiration date:
      1. The system will archive prior approvals where the treatment date is in the future and after the updated insurance expiration date.
      2. The system will not archive prior approvals where the treatment date is in the past.
2. New insurance added (insurance does not match existing insurance):
   1. If the new insurance sent does not include an expiration date, the system will archive prior approvals from the effective date of the new insurance forward.
   2. If the new insurance sent has an expiration date that is today or in the future, the system will archive prior approvals where the treatment date is in the future.
   3. If the new insurance sent has a past expiration date (this a retroactive update):
      1. The system will not archive prior approvals where the treatment date is in the past.
      2. The system will not inactivate the existing insurance that has an effective date beyond the expiration date of the retroactive update sent. The system will not archive prior approvals from the past or future. If there is ambiguity due to overlapping or unspecified effective or expiration dates on the existing insurance, the system will archive the approvals from the date that the interface update message was sent forward. The prior insurance will however remain active and thus available for use.