Prior Auth Eligibility & Pre Screen Agent

HIP One Prior Auth Eligibility & Pre-Screen Agent

HIP One Prior Auth Eligibility & Pre-Screen Agent is an intelligent administrative gate that deflects ineligible prior authorization requests in under 500 milliseconds — with >95% screening accuracy and a <0.5% false-positive rate — so clinical reviewers only see cases that actually need clinical judgment.

Key Features

• Member Eligibility: Verifies coverage is active at date of service, benefit design includes the requested service, and the correct plan type is applied.

• Provider Eligibility: Confirms NPI is active, provider is enrolled in the payer network, not excluded (OIG LEIE, SAM.gov), and specialty is appropriate.

• Program Eligibility: Checks whether the service category requires prior auth, geographic jurisdiction applies, and exemptions such as gold-card or emergency are honored.

• Duplicate Detection: Identifies exact and substantial duplicates, resubmissions after denial, existing active authorizations, and device replacements.

• Code Validation: Validates CPT/HCPCS codes, NCCI bundling edits, Medically Unlikely Edits, modifier appropriateness, and diagnosis-procedure pairing.

• Category Admin Rules: Applies service-category-specific requirements including facility credentialing, ordering provider specialty, step therapy compliance, and site-of-service rules.

Gate Decisions

Every request is classified into one of eight legally distinct dispositions — each with the correct appeal rights, notification target, and regulatory metadata pre-attached:

• GATE-NONCOV: Service not covered under the benefit design.

• GATE-NOTENROLLED: Member or provider not enrolled.

• GATE-NOPA: Service does not require prior authorization.

• GATE-DUPLICATE: Duplicate of an existing request.

• GATE-STOP: Hard coding failure requiring provider resubmission.

• GATE-LIMIT: Partial authorization with approved units issued.

• GATE-REDIRECT: Wrong entity or jurisdiction, redirected with contact info.

• GATE-EXEMPT: Qualifies for prior auth exemption (gold-card, emergency).

Supported Formats

Accepts prior authorization requests in FHIR PAS Bundles, HIPAA X12 278 transactions, JSON REST API payloads, HL7 v2 messages, faxed documents, webhooks, and batch files. Returns CMS-0057-F-aligned electronic responses with structured reason codes, appeal rights, and decision timelines. Works across Medicare FFS, Medicare Advantage, Medicaid FFS, Medicaid Managed Care, and commercial insurance across all U.S. jurisdictions.

Deployment Options

• Standalone: Deploy as a pre-filter in front of any existing UM platform. Gated requests are returned with structured dispositions; pass-through requests flow to your current workflow unchanged.

• Integrated with HIP One: Pass-through requests flow directly into HIP One's multi-agent clinical determination pipeline for full evidence assessment and policy matching.

Infrastructure and Support

Deployed on Microsoft Azure, ensuring every decision is secure, auditable, and compliant — HIPAA-aligned with full BAA chain, PHI encrypted at rest (AES-256) and in transit (TLS 1.3), per-tenant isolation, HITRUST CSF-aligned controls, and a complete audit trail for every gate decision. The agent issues administrative dispositions only — never clinical denials. Ambiguous cases are flagged for human review. Full support for both the application and infrastructure is provided.

User Roles

HIP One Prior Auth Eligibility & Pre-Screen Agent supports two primary user roles:

• Admin: Manages users, permissions, and oversees the application settings.

• User: Submits prior authorization requests, reviews gate decisions, and manages disposition workflows.