Problem Statement

When a patient is admitted, the payer must be notified within a tight window, often within a day or two of admission, or the stay is denied regardless of whether the care was necessary. Sending each Notice of Admission manually is labor-intensive and easy to let slip while staff focus on the admission itself, and a notice that goes out late, or not at all, becomes an avoidable denial on an inpatient stay the organization has already begun delivering. For qualifying Blue Cross Blue Shield (BCBS) admissions, the request goes through Rhyme, a third-party integration that connects the EMR to the payer. Utilization Management also keeps reviewing the stay until the payer responds, so nurses reopen accounts with nothing new to review while the authorization is still pending.

Automation Solution

This automation is triggered when a qualifying admission lands in the Utilization Management workqueue and initiates the request through the EMR's Rhyme integration, which submits it to the payer and returns the response. Once the payer responds, it sets the next review date 15 days out so the stay isn't re-reviewed until there is a reason to.