Manage authorizations

Outcome

Service authorizations are requested, tracked, and renewed in time, the right 278 transaction is sent or the manual queue is worked, and members have visible utilization meters so a clinician knows when an auth is about to run out.

Prerequisites

Scope	What it lets you do
clinical.authorization.read	View list / detail / utilization
clinical.authorization.write	Create / submit / cancel

Eligibility verified for the member (3.4 — Run an eligibility check or sweep) — submitting an auth for an unenrolled member wastes the payer's response cycle.

Workflows

A program's authorizationWorkflow setting drives behavior:

Setting	Behavior
AUTOMATIC_278	The platform composes and submits an X12 278 request. The payer's 278 response triggers APPROVED / DENIED / PENDED.
MANUAL_PENDING	Auth requests sit in a manual queue; staff submit through the payer's portal and record the response by hand.
NONE	The program does not require auths; auth records are not created.

See 5.1 — Payers, programs & contracts to set the workflow per program.

The list page

/authorizations filters:

Filter	Default
Status	DRAFT, SUBMITTED, APPROVED, PENDED
Member	All
Payer	All
Expiring within	All

Each row shows member, payer, service codes, approved units, used units, remaining units, effective window, status.

The detail page

Click into /authorizations/:id.

Tab	Purpose
Overview	Header — member, payer, codes, units, dates. Approval source (278 or manual).
Utilization	Bar showing used vs. approved, plus a per-month breakdown.
Linked claims	Claims that drew from this auth.
Communication	Notes; visible in audit log.
Documents	Approval letter, denial letter.

Steps to request an auth

1. Open the member at /members/:id. Click + New authorization. (You can also start from /authorizations → + New.)

2. Fill the form:

   Field	Notes
   Payer + program	Drives the workflow.
   Service codes	Multi-select from code_set_procedure.
   Modifiers	Optional.
   Approved units	What you are requesting (the payer may approve fewer).
   Effective window	Defaults to 90 days; payer-specific defaults override.
   Diagnosis	ICD-10.
   Place of service	POS code.
   Provider	Rendering provider.

3. Click Save as draft to keep editing, or Submit to fire the 278 (for AUTOMATIC_278 programs) or to push the request into the manual queue (MANUAL_PENDING).

4. Watch the response. For AUTOMATIC_278:

   • SUBMITTED while awaiting the payer's 278 response.
   • APPROVED with the payer's approved units (may be less than requested).
   • DENIED with the reason carried in the 278 detail.
   • PENDED if the payer needs more info.

   For MANUAL_PENDING, a staff member opens the auth and uses Record response to type in the payer's decision from the portal.

Steps to handle a PENDED auth

1. Open the auth. The Communication tab shows the payer's pend reason.

2. Attach the requested document (Documents tab → Upload).

3. Click Resubmit (for AUTOMATIC_278 — the platform sends a 278 follow-up payload) or Record response (for MANUAL_PENDING — once the portal returns a decision).

Steps to renew

The list page surfaces auths expiring within 30 days. For each:

1. Click Renew. The platform copies the auth's parameters into a new draft, including the same codes / units; you adjust dates and units as needed.

2. Submit. The new auth's parentAuthorizationId points at the old auth so the chain stays visible in the member's history.

Validation

Check	Expected
Submission produces a SUBMITTED row	Yes.
278 response updates the row to APPROVED / DENIED / PENDED within minutes	Yes (for AUTOMATIC_278).
Linked claims tab populates as the auth gets used	Yes.
Utilization meter increments on each linked claim	Yes.

Troubleshooting

Symptom	Cause	Fix
Submit greyed	Program is NONE (no auths)	Confirm the program; if it should require auths, change the program config (5.1).
278 response not arriving	Trading partner not configured for 278 capability	Add the capability (5.6 — Trading partner credentials).
Utilization shows wrong used count	A linked claim was voided but the utilization did not roll back	Open the auth → Recalculate; the platform re-derives utilization from the current claim set.
Manual auth approved but charges still flag auth required	The auth was approved for different procedure codes than the charges carry	Compare service codes on the charge vs. the auth; either fix the charge code or amend the auth.

Next

3.4 — Run an eligibility check or sweep