Overview
Creating a prior authorization rule in NikoHealth helps ensure that the system automatically validates whether a 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 the Order process and the Invoice (claims) process.
Before creating prior authorization rules for a Payer, we recommend you read our article on managing prior authorizations in NikoHealth.
Create a Prior Authorization Rule
To create a new authorization rule for a Payer, navigate to the Payer by going to: Management > Billing Setup > Payers
Select the Payer you're creating the authorization rule for. This will allow you to edit information about this Payer. Click on the Rules tab to see any existing Payer Rules, and to create new Payer Rules.
Under Payer Rules, in the Authorization tab, you have options for creating a Product specific rule or a generic rule.
Auth Rule Options
Payer rules let you 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).
Product Specific Rule
You can define the CPT/HCPCS codes or products from your catalog that will require prior authorization.
Payer or Plan
Create a Payer Rule if you are setting up rules for the Payer as a whole. This will 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.
Monitor and Adjust
Once all the criteria for prior authorization are defined, click the Save or Apply button to store the rule. Ensure that the rule is applied to the correct Payer and Plan combination. Once set up, the system will automatically check if a service requires prior authorization and tag Orders or claims accordingly.
It's important to monitor your workflow and ensure that the system is tagging Orders and claims correctly. If issues arise, review the authorization rule and make adjustments as necessary. Be sure to update the rules periodically to reflect changes in Payer policies, new services, or adjustments in prior authorization requirements.
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.