7 results about "Prior authorization" patented technology

Systems and methods for providing an intelligent network to onboard patients to specialty medications are described herein. A server system for managing communication is configured to receive from a user at a healthcare practice, an electronic request to obtain a medical prior authorization (medPA) for a specialty drug to administer for a patient of the healthcare practice; select, using a rules service, a communication pathway to submit the medPA to a healthcare payer from a plurality of communication pathways; and initiate a connection with the healthcare payer using the selected communication pathway.

A computerized method for analyzing prior authorization documentation includes receiving a first set of information including a set of pages and determining a set of relevant pages. The method includes determining a set of document types associated with the set of relevant pages and performing optical character recognition. The method includes prompting a machine learning model to extract a set of request data. The method includes prompting the machine learning model with a set of prompts associated with a set of authorization criteria to determine a set of authorization data. The method includes, in response to a determination that the set of authorization data has met the set of authorization criteria, approving an authorization request. The method includes, in response to a determination that set of authorization data has not met the set of authorization criteria, rejecting the authorization request.

An intelligent dosing platform system for prior authorization and pharmacy benefit management comprising intelligent injection devices with prior authorization modules configured to receive medication release approval from pharmacies, distributing agents, and payor entities. The system analyzes authorization requirements by evaluating individual payor policies, pharmacy benefit manager formulary restrictions, step therapy requirements, medical necessity criteria, seasonality factors, and timing considerations. An automated decision engine determines authorization approval or denial based on real-time policy evaluation and aggregated device usage data from multiple injection devices. An action coordinator triggers downstream processes including preventing device shipment, updating electronic health records, and coordinating billing system updates. A financial reconciliation module ensures one-to-one correspondence between authorization approvals and fulfillment activities, matching approved medications with actually shipped or administered medications while preventing payment for unapproved medications.

System and methods for providing interoperable, automated, real-time genetic efficacy contraindication checks are provided. Coverage requests involving for medications for patients from nodes of an electronic network. A testing results query is made for each request at database(s) with identifying information for the patients to determine if genetic efficacy testing results are available. If so, a testing results query is performed to determine if any of the medications in a respective coverage request are contraindicated for a respective patient based on the genetic efficacy testing results. And, if so, a standardized, encoded message is returned to the originating node for the respective coverage request query indicating each contraindicated medication.

A method is provided for dynamic authorization based on execution path status. The method includes identifying a plurality of execution paths in prior authorization data, in which each execution path contains a plurality of nodes. The identified plurality of execution paths are ranked according to probability. At least part of a most probable execution path from among the ranked plurality of execution paths is determined for a current user based on a current node. Node access authorizations are automatically generated based on the at least part of the determined most probable execution path.

Systems and methods for providing an intelligent network to onboard patients to specialty medications are described herein. A server system for managing communication is configured to receive from a user at a healthcare practice, an electronic request to obtain a medical prior authorization (medPA) for a specialty drug to administer for a patient of the healthcare practice; select, using a rules service, a communication pathway to submit the medPA to a healthcare payer from a plurality of communication pathways; and initiate a connection with the healthcare payer using the selected communication pathway.

A trained predictive server is provided for determining that a diagnosis and treatment plan is inaccurate. The trained predictive server includes a processor configured to receive a set of prior authorization (PA) data associated with a medical claim for a patient, and determine that the PA data indicates that the medical claim is associated with a qualifying critical illness and control use of medical devices. The processor can extract component data from the set of PA data, and apply the extracted component data to a predictive model associated with the qualifying critical illness to determine whether the medical claim is associated with an inaccurate diagnosis and treatment plan. Upon determining that the medical claim is associated with an inaccurate diagnosis and treatment plan, the processor can generate a request for review of the diagnosis and treatment plan using the set of PA data and stop use of a medical device.