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. Whether a visit needs authorization is driven by Epic's Authorization Service Area (ASA) table, and payers continually change which CPT codes require it. When the table lags, the organization either misses a required authorization or chases one that was never needed. Keeping it current took three teams. A specialist ran roughly 40 separate scripts to pull payer plan data and mapped the results into the ASA master file manually, a Central Authorization analyst reviewed the mapping, and IT uploaded the changes. The manual mapping is slow and error-prone, and the lag between a payer's change and the table update is where preventable denials start.

Automation Solution

This automation extracts payer plan data from payer websites, compares it against the ASA master file, and updates the file to reflect CPT codes added to or removed from authorization requirements. It then notifies the transformation and IT teams that the file is ready for import into Epic.