Problem Statement

Authorizations must be handled within tight payer timeframes, and doing it manually is labor-intensive, so a missed or late authorization becomes an avoidable denial. Radiology is especially exposed because many advanced imaging studies require prior authorization through a benefits manager, so each upcoming visit has to be checked against Carelon's guidelines before service to confirm whether an authorization is needed. When that determination is slow or skipped, the imaging proceeds and the denial follows.

Automation Solution

This automation checks Carelon guidelines to determine whether upcoming Radiology visits require authorization and updates the EMR with the authorization requirement.