Authorization Management - Technical Specification

Prior authorization and service approval system

Purpose

The Authorization Management module handles the pre-approval of medical services for legal cases. Every appointment, service, treatment, and procedure requires an authorization number linked to the legal case. The system features an auto-approval backend service for Dates of Service (office visits) while managing complex authorization rules for specialized services. This module ensures services are approved before delivery and tracks utilization against authorized limits.

Key Concepts

Term	Definition
Authorization	Pre-approval for medical services
Authorization Number	Unique identifier for each authorization
Auto-Approval	Automatic authorization for routine services
DOS (Date of Service)	Office visit dates that are auto-approved
Authorization Period	Valid date range for the authorization
Units/Visits	Number of services authorized
Utilization	Actual usage against authorized amount
Prior Authorization	Approval required before service delivery
Retro Authorization	Approval granted after service (exception)
Authorization Status	Current state (Approved, Pending, Denied, Expired)

User Roles

Role	Description	Permissions
Authorization Specialist	Manages authorization requests	Full CRUD
Medical Director	Reviews complex authorizations	Approve, Deny
Case Manager	Requests authorizations	Create, Read
Provider	Views authorizations	Read only
Claims Processor	Validates auth for claims	Read only
System Administrator	System configuration	All permissions

Field Documentation - Authorization Entity

Field Name	Type	Required	Description	Validation Rules	Related Entity
ID	String	Yes	Unique authorization ID	Auto-generated CUID	Primary Key
Authorization Number	String	Yes	Human-readable auth number	Format: AUTH-YYYY-XXXXXXX, unique	-
Legal Case	LegalCase	Yes	Associated legal case	Must be active case	LegalCase
Patient	Patient	Yes	Patient receiving services	Must match case patient	Patient
MRN	String	Yes	Member Registration Number	From legal case	-
Requesting Provider	ClinicalProvider	No	Provider requesting auth	Valid provider	ClinicalProvider
Authorized Provider	ClinicalProvider	Yes	Provider authorized to render	Must be active	ClinicalProvider
Authorized Vendor	Vendor	Yes	Vendor authorized	Must be active	Vendor
Service Location	VendorLocation	No	Specific location authorized	Valid vendor location	VendorLocation
Authorization Type	String	Yes	Type of authorization	Enum: Initial Eval, Follow-up, Therapy, Imaging, Surgery, DME, Other	-
Service Category	String	Yes	Category of service	Enum: Medical, Therapy, Diagnostic, Surgical, Equipment	-
CPT Codes	String	No	Specific CPT codes authorized	Comma-separated CPT codes	-
Service Description	Text	Yes	Description of authorized services	Max 1000 chars	-
Units Authorized	Integer	Yes	Number of units/visits	Positive integer (1-999)	-
Units Used	Integer	Yes	Units consumed	Calculated field, >= 0	-
Units Remaining	Integer	Yes	Units available	Calculated: Authorized - Used	-
Authorization Start Date	DateTime	Yes	Authorization effective date	Cannot be before case start	-
Authorization End Date	DateTime	Yes	Authorization expiration	Must be after start date	-
Date Requested	DateTime	Yes	When auth requested	Auto-set on creation	-
Date Reviewed	DateTime	No	When auth reviewed	Set on status change	-
Reviewed By	User	No	User who reviewed	Valid user ID	User
Authorization Status	String	Yes	Current status	Enum: Pending, Approved, Denied, Expired, Cancelled	-
Status Reason	String	No	Reason for status	Required for Denied	-
Denial Reason	String	No	Specific denial reason	Required if Denied	-
Auto Approved	Boolean	Yes	Was auto-approved	Default false	-
Auto Approval Reason	String	No	Why auto-approved	Set by auto-approval engine	-
Priority	String	Yes	Request priority	Enum: Routine, Urgent, Emergency	-
Clinical Notes	Text	No	Clinical justification	Max 5000 chars	-
Diagnosis Codes	String	Yes	ICD-10 codes	Comma-separated, valid ICD-10	-
Medical Necessity	Boolean	Yes	Medically necessary	Default true	-
TPA Review Required	Boolean	Yes	Needs TPA review	From contract rules	-
TPA Review Status	String	No	TPA review outcome	Enum: Pending, Approved, Denied	-
TPA Review Date	DateTime	No	When TPA reviewed	If TPA required	-
TPA Reference Number	String	No	TPA tracking number	From TPA system	-
Estimated Cost	Decimal	No	Estimated service cost	Positive decimal	-
Actual Cost	Decimal	No	Actual cost from claims	Sum of related claims	-
Related Authorization	Authorization	No	Parent/related auth	For extensions/modifications	Authorization
Extension Of	Authorization	No	Original authorization	For extensions	Authorization
Modified From	Authorization	No	Previous version	For modifications	Authorization
Retroactive	Boolean	Yes	Approved after service	Default false	-
Retroactive Reason	String	No	Why retro approved	Required if retroactive	-
Notification Sent	Boolean	Yes	Provider notified	Default false	-
Notification Date	DateTime	No	When notified	Set when sent	-
Attachments	Document[]	No	Supporting documents	Medical records, notes	Document (1:Many)
Created At	DateTime	Yes	Creation timestamp	Auto-generated	-
Updated At	DateTime	Yes	Update timestamp	Auto-updated	-
Created By	User	Yes	Creating user	Valid user ID	User
Updated By	User	Yes	Updating user	Valid user ID	User
Appointments	Appointment[]	No	Related appointments	-	Appointment (1:Many)
Claims	Claim[]	No	Related claims	-	Claim (1:Many)

Workflows

Authorization Request Workflow

1. Request Initiation

   • Select legal case
   • Verify patient eligibility
   • Choose service type
   • Select provider/vendor

2. Service Details

   • Specify CPT codes or service description
   • Set number of units/visits
   • Define authorization period
   • Add clinical justification

3. Auto-Approval Check

   • Check if service qualifies for auto-approval
   • Office visits (E&M codes) → Auto-approve
   • Initial evaluations → Auto-approve
   • Other services → Manual review

4. Manual Review Process

   • Route to appropriate reviewer
   • Check medical necessity
   • Verify against guidelines
   • Review clinical notes

5. Decision

   • Approve with conditions
   • Deny with reason
   • Request additional information
   • Refer to Medical Director

6. Notification

   • Generate authorization number
   • Notify provider
   • Update case record
   • Send to patient if required

Auto-Approval Engine Workflow

1. Service Evaluation

   IF service_type = 'Office Visit' AND provider_valid THEN
      Auto-approve
   ELSE IF service_type = 'Initial Evaluation' AND first_visit THEN
      Auto-approve
   ELSE IF cpt_code IN auto_approve_list THEN
      Auto-approve
   ELSE
      Manual review required

2. Automatic Processing

   • Validate provider credentials
   • Check case status
   • Verify service parameters
   • Generate authorization number
   • Set appropriate limits

3. Audit Trail

   • Log auto-approval reason
   • Record decision criteria
   • Track approval pattern
   • Monitor for abuse

Utilization Tracking Workflow

1. Appointment Booking

   • Link appointment to authorization
   • Decrement available units
   • Check remaining balance
   • Alert if near limit

2. Claim Processing

   • Match claim to authorization
   • Verify DOS within auth period
   • Update units used
   • Calculate remaining

3. Extension Process

   • Monitor utilization
   • Alert at 80% usage
   • Process extension request
   • Link to original auth

Retroactive Authorization Workflow

1. Exception Request

   • Document emergency/urgent situation
   • Provide clinical justification
   • Explain why prior auth not obtained
   • Submit supporting documentation

2. Review Process

   • Verify emergency criteria
   • Check medical necessity
   • Review documentation
   • Make determination

3. Approval/Denial

   • If approved, generate retro auth number
   • Link to existing claims
   • Document exception reason
   • Update financial records

Business Rules

Auto-Approval Rules

• Office visits (CPT 99201-99215) auto-approved
• Initial evaluations auto-approved (first visit only)
• Maximum 12 office visits auto-approved per case
• Auto-approval only for credentialed providers
• DOS must be within case active period

Authorization Limits

• Maximum authorization period: 6 months
• Maximum units vary by service type:
  • Office visits: 12 per auth
  • Physical therapy: 24 visits
  • Chiropractic: 12 visits
  • Imaging: As specified
• Extensions require new authorization

Validation Rules

• Provider must be credentialed
• Service must be within scope of practice
• DOS cannot precede authorization start
• Cannot exceed case financial limits
• Diagnosis must support service

TPA Requirements

• TPA review required based on contract
• Certain CPT codes always need TPA
• Dollar thresholds trigger TPA review
• TPA decision is binding
• TPA turnaround: 3 business days

Integrations

System	Integration Type	Purpose
Legal Case Management	Direct Database	Case validation
Provider Management	Direct Database	Provider verification
Appointment System	Direct Database	Utilization tracking
Claims Processing	Direct Database	Authorization validation
TPA Systems	API/EDI	External review
Notification System	Email/Fax	Provider notifications
Document Management	File System	Attachment storage

Common Issues

Issue	Description	Resolution
Units Exceeded	Service exceeds authorized units	Request extension
Expired Authorization	DOS after expiration	Retroactive auth or extension
Provider Mismatch	Different provider than authorized	Update authorization
Missing Auth	Service without authorization	Create retro auth
TPA Delays	TPA review taking too long	Escalation process

Screenshots Needed

• Authorization Request Form
• Auto-Approval Configuration
• Authorization Search Grid
• Authorization Detail View
• Utilization Tracking Dashboard
• Review Queue Interface
• Extension Request Form
• Retroactive Auth Wizard
• TPA Review Status
• Provider Notification Template

Performance Considerations

• Auto-approval must be instant
• Authorization lookup sub-second
• Utilization calculation real-time
• Bulk authorization processing
• Historical auth data archival

Security Considerations

• PHI protection for clinical notes
• Audit trail for all decisions
• Role-based approval limits
• Provider access restrictions
• Financial limit enforcement

Notes

• Auto-approval rules configured per payer
• Authorization numbers are sequential per year
• Extensions maintain original auth number with suffix
• TPA integration requirements vary by contract