Overview
Creating a prior authorization rule in NikoHealth helps ensure that the system automatically validates whether prior authorization is required for specific services or products. This process can be applied to individual payers or specific payer plans, and is designed to automate the tracking and handling of authorizations during both the order and invoicing (claims) processes.
How to Create a Prior Authorization Rule
1. Navigate to the Billing Setup Section
Go to the Management Section: From the main dashboard, navigate to the Management section.
Select Billing Setup: Under the management options, find and click on Billing Setup. This section handles payer configurations, billing rules, and related tasks.
2. Locate the Payer
Find the Payer: Once in the Billing Setup, look for the Payers section. Here, you will see a list of all the payers (insurance companies) that your organization works with.
Select the Payer: Find and click on the payer you wish to create the prior authorization rule for. This could be a specific payer like "ABC Health Plan" or "XYZ Insurance."
3. Access the Rules Tab
Click on the Rules Tab: After selecting the payer, look for the Rules tab within the payer configuration section.
Select Authorizations: Under the Rules tab, you'll see a variety of rule options. Click on Authorization to create or modify prior authorization rules for that payer.
4. Define Prior Authorization Criteria
In this section, you can specify the conditions under which prior authorization is required for services or products. You’ll be able to define rules either at the payer level or for a specific payer plan (e.g., PPO, HMO).
Creating a Rule for a Payer or Plan
Create a Payer Rule: If you are setting up rules for the payer as a whole, you can configure rules for all plans under that payer.
Create a Plan-Specific Rule: If the prior authorization requirements differ by plan type (e.g., PPO, HMO, or specific plans), create a rule for that specific payer plan.
Defining Services/Products that Require Prior Authorization
Service/Product Specificity: In this section, you can define the CPT/HCPCS codes, or products that will require prior authorization.
CPT/HCPCS Codes: You can enter specific CPT or HCPCS codes for services that require prior authorization.
Products: If you're working with specific products you can specify which products require authorization.
6. Save the Rule
Save the Rule: Once all the criteria for prior authorization are defined, click the Save or Apply button to store the rule.
Confirm Rule Creation: Ensure that the rule is applied to the correct payer and plan combination.
7. Monitor and Adjust
Monitor Workflow: Ensure that the system is tagging orders and claims correctly. If issues arise, review the authorization rule and make adjustments as necessary.
Update Rules: Update the rules periodically to reflect changes in payer policies, new services, or adjustments in prior authorization requirements.
Key Takeaways
Payer-Specific Rules: You can create rules for an entire payer or for specific payer plans (e.g., PPO, HMO).
Service/Product Specificity: Define which services (via CPT/HCPCS codes) or products require prior authorization.
Automation: Once set up, the system will automatically check if a service requires prior authorization and tag orders or claims accordingly.
By setting up prior authorization rules in NikoHealth, you ensure that claims and services are processed in compliance with payer requirements, reducing administrative burden and improving operational efficiency.