CareCentrix has helped payors and providers lower costs of managing home health care for over 20 years. It has achieved this through a great degree of business process automation.
One process that still required a lot of manual work was the resolution of authorization exceptions or “elevation”, and it was a time-intensive and expensive process to manage.
CareCentrix wanted to streamline and automate the workflow by integrating their system with their customers’ systems. This would allow out-of-policy requests to be sent electronically to a health plan to review and return the resolution instructions to CareCentrix, eliminating a lot of staff time on the phone.
Tallan engaged with CareCentrix to design and build a solution to automate their “elevation” process, allowing authorization request information to be electronically sent to and received from the health plan.
The solution integrated the CareCentrix elevation workflow system with their customers’ systems. When an authorization meets specific business rules it is now routed directly to the health plan system where their staff review and determine the appropriate resolution.
The resulting decision is then returned to the CareCentrix authorization process. Upon receiving the health plan’s decision, the CareCentrix system then routes the request to the next step in the workflow.
A user interface allows staff to review the current status of elevated authorization requests that are sent and received from the healthplan. This solution eliminates the need for CareCentrix staff to pick up the phone to call the health plan to manage the elevation process.