Process Group
Beneficiary Management
Objective
Provider has secured timely assurance from insurer that proposed service will be admissible for payment through claim settlement
Ensure beneficiary beneficiary receives efficient and effective utilization of services
Protect payer from unnecessary costs
Input
Beneficiary identifier
Benefits class
Clinical information
Supporting documents
Treatment plan
Diagnosis
Output
Approval with cost, service or unit boundaries or rejection
Approval/ provisional approval (services can proceed but services may not be covered) disapproval
Approval percentage (percentage of requests that are approved)
Analysis of which services are being rejected (what provider, what services)
Measurable Outcomes
Timely response to pre- authorization
Approval of (time/cost and or unit based) list of services
Financial metrics
Fraud resolution
Supports quality of care
Patient satisfaction
Accounts of insurer notified