Prior authorization requirements and Utilization Management capabilities
Key Takeaway
Match the question to the capability: Coverage Requirement Discovery for whether prior authorization is needed, Documentation Templates and Rules for what documentation the payer needs, and Prior Authorization Support for submitting and reviewing the request.
Utilization Management (UM) in Agentforce Health digitizes two jobs: providers asking for prior authorization (PA) of a medical service, and payers deciding whether that service is medically necessary and covered. UM replaces phone calls, faxes and manual re-entry with FHIR-aligned data exchange, business rules and guided workflows across the whole UM lifecycle. The goal is the right care, at the right time, for the appropriate duration and in the right setting, while controlling cost.
What prior authorization is
If a service needs PA...
The provider submits a request to the payer.
If a service doesn't need PA...
The provider can perform the service with the assurance that it will be covered.
PA requirements are complex and vary by payer, plan and service. Imaging tests, surgical procedures, specialty medications, rehabilitation services and mental health services commonly need PA. Routine office visits, preventive care, diagnostic tests and simple surgical procedures sometimes don't.
Requests sent for services that don't need PA still delay care for patients, so the first question is whether a request is required at all.