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Prior authorization

Prior authorizations help payers ensure that a prescribed treatment is medically necessary for a patient. Prior authorizations typically require clinical information and supporting documentation provided by a healthcare provider to demonstrate the need for the prescribed product. Prior authorizations are managed by the Prior Authorization (mvn__PJN_Prior_Authorization__c) custom object and can be created in Member Plan (mvn__PJN_Member_Plan__c) records.

Note

Out of the box, if you create a Prior Authorization record from a Member Plan record that is related to a Coverage Investigation (mvn__PJN_Coverage_Investigation__c) record and the Coverage Investigation record has a Status (mvn__PJN_Status__c) value of Pending or In Progress, the prior authorization will automatically be related to the coverage investigation. This is managed by the Prior Authorization: KCC Before Insert (mvn__PJN_Prior_Authorization_Before_Insert) flow.

Electronic prior authorization (ePA)

Komodo Care Connect supports integrations with external vendors to facilitate the electronic submission and processing of prior authorizations. With electronic prior authorization (ePA), users can submit prior authorization requests from Komodo Care Connect as well as receive updates and results within Komodo Care Connect via a designated ePA provider. To set up and configure the electronic prior authorization (ePA) functionality, reference Electronic prior authorization (ePA).

Note

The ePA functionality currently only supports a single ePA vendor for each care program.

To submit an ePA request for a care plan from Komodo Care Connect:

  1. Create a Member Plan (mvn__PJN_Member_Plan__c) record on the care plan.

  2. On the Member Plan record, click Submit ePA. The "ePA Data To Be Transmitted" modal will open.

  3. Review the information in the "ePA Data To Be Transmitted" modal that will be sent to the designated ePA vendor for the care program. The fields in the modal are configured via the ePA Field Mapping (mvn__PJN_Epa_Field_Mapping__mdt) custom metadata type. If there are required fields that are blank, users must close the modal to enter any missing information. If all required fields are filled out, users can click Submit JSON to submit the ePA request.

Once the ePA request is submitted, a new Prior Authorization record will automatically be created on the parent Member Plan record. (Users may need to refresh the tab to see the Prior Authorization record.) The ePA vendor will subsequently review and make a decision on the request. When the vendor responds to the request, the Prior Authorization record will also automatically be updated with the outcome of the request, including the effective and expiration dates or denial reasons as appropriate.