A key way for health care payers to maximize organizational
effectiveness is to reduce or eliminate time-intensive manual
workflow processes. Freeing up clinical staff to focus on care
management and other, more substantive member-centric concerns
helps improve care and increase overall operational efficiencies.
Ultimately, this can contribute to more favorable outcomes and
organization-wide cost containment.
Alineo Automated Approvals enables health care payers to create
rules that automatically evaluate requests for service (referrals,
authorizations, extensions, etc.) submitted through Alineo. Alineo
Automated Approvals is a comprehensive and flexible tool with which
payers can apply consistent decision making processes to
transactions regardless of where they initiate. This minimizes the
need for human intervention and manual administration, streamlining
transactional workflows. In addition, since it can be extended to
physicians through Nexalign™ iEXCHANGE or individual provider
portals, Alineo Automated Approvals facilitates greater messaging
and clinical consistency.
Alineo Automated Approvals is embedded with clinical criteria
that establishes pre-existing clinical rules. However, one of its
primary features is an inherent flexibility that enables payers to
create customized rules according to various clinical and
organizational needs to determine the result of a request. Possible
results include:
- Auto-Approve
- Pend
- Pend With Message: Alerts the user that the request can be
approved if the number of units, visits or days requested is
modified. Otherwise, the request will pend.
- Ask Additional Authorization Questions: Allows the user to
answer additional questions that may impact the result of the
request. Questions are created by the payer in the Alineo
questionnaire module.
Payers also have the ability in Alineo Automated Approvals to
create custom messages associated with auto-approval rules. This
enables payers to further enhance automation by educating providers
as part of the request submission process.