Prior Authorization Decision Trees from Relational Database Entries
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Solution Overview
Problem
Current methodologies for programmatically executing automatic authorizations, such as prior authorizations in healthcare, do not provide exhaustive, unambiguous, and synoptic management and maintenance of prior authorization requirements, leading to inconsistencies, gaps, and errors in data input, updating, searching, viewing, and analyzing across disparate systems.
Innovation Solution
The development of a system that uses relational database tables to populate fields with prior authorization requirements, generating decision trees based on these requirements, and traversing them to provide responses to prior authorization requests, ensuring comprehensive and consistent management and accessibility of authorization data.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Reliability
If current methodologies are used for programmatically executing automatic authorizations, then the system is simpler to implement, but the management and maintenance of prior authorization requirements becomes inconsistent and error-prone
Solution Approach 1:
The patent segments prior authorization requirements into discrete, structured data elements stored in relational database tables. Each requirement is broken down into specific fields (e.g., authorization type, criteria, duration) that can be independently managed and queried, eliminating inconsistencies while maintaining system manageability through modular data organization.
Solution Approach 2:
The patent introduces a standardized data interface layer between the authorization requirements and the execution system. This intermediary layer uses uniform data structures and query protocols that enable consistent access and management of prior authorization data across disparate systems without requiring complex point-to-point integrations.
2Adaptability or versatility
If disparate systems are used for prior authorization management, then system flexibility is maintained, but data accessibility and consistency across systems deteriorates
Solution Approach 1:
The patent creates a universal data structure for prior authorization requirements that can be accessed by multiple different systems and applications. The standardized relational database schema and query interface enable any authorized system to access and execute authorization checks consistently, providing broad interoperability while maintaining data integrity across the entire ecosystem.
3Reliability
If manual methods are used for managing prior authorization requirements, then implementation complexity is reduced, but the exhaustiveness and completeness of authorization coverage decreases
Solution Approach 1:
The patent implements self-service capabilities where the system automatically populates, updates, and maintains prior authorization requirements in the relational database. The structured data model enables automated querying, validation, and execution of authorization checks without manual intervention, ensuring exhaustive coverage of all authorization scenarios while reducing operational complexity through automation.
Data Source
AI summary
Methods, apparatus, systems, computing devices, computing entities, and/or the like for programmatic methodologies for determining and providing prior authorization requirements in a way that facilitates inputting information/data, updating information/data, searching information/data, viewing information/data, reporting information/data, and analyzing information/data while being broadly accessible to disparate systems.