Abstract: A preauthorization management system. The preauthorization management system allows a health care provider to submit a preauthorization request and track the status of the preauthorization request until a final determination is reached. Once a request has been submitted, the preauthorization management system monitors the status of the request until a final disposition is reached. The preauthorization management system documents the submission and determination process to provide a record that may be used to show an event or outcome occurred. The preauthorization management system offers a simplified and uniform system for managing preauthorization for health care services that reduces or eliminates the need for health care providers to learn diverse systems and procedures of a multitude of health insurance providers.

Abstract: Normalizing codified data in an eligibility response and proactively identifying insurance eligibility and benefit documentation issues is provided. Data in an eligibility response may be mapped with other data including data received from healthcare providers, payers, data from inquiries, etc. The data may be stored in tables, and/or in internal and external databases. If there are any determined issues discovered, an alert of the issue found is embedded in the response or the determined issue may be automatically corrected. The alert may provide an instruction on how to rectify the issue to a healthcare provider administrative user. The formatting and structure of the eligibility response may be normalized such that message segments relating to a same service type are grouped together, providing a consistently formatted normalized response. Accordingly, an end user may be able to more easily find information in the normalized eligibility response.

Abstract: A preauthorization knowledgebase system. The preauthorization knowledgebase system parses relevant information from an order submitted by a health care provider and compares that information against a set of rules used to determine whether preauthorization is required for a medical service specified in the order. The rules are arranged into various hierarchical levels from payer level to procedure level. Even if the order is incomplete, the preauthorization knowledgebase system checks as many of the hierarchical levels as possible with the information provided. The preauthorization knowledgebase system returns a result indicating whether preauthorization is required for the order and, optionally, the hierarchical level(s) requiring preauthorization.

Abstract: A preauthorization management system. The preauthorization management system allows a health care provider to submit a preauthorization request and track the status of the preauthorization request until a final determination is reached. Once a request has been submitted, the preauthorization management system monitors the status of the request until a final disposition is reached. The preauthorization management system documents the submission and determination process to provide a record that may be used to show an event or outcome occurred. The preauthorization management system offers a simplified and uniform system for managing preauthorization for health care services that reduces or eliminates the need for health care providers to learn diverse systems and procedures of a multitude of health insurance providers.

Abstract: Normalizing codified data in an eligibility response and proactively identifying insurance eligibility and benefit documentation issues is provided. Data in an eligibility response may be mapped with other data including data received from healthcare providers, payers, data from inquiries, etc. The data may be stored in tables, and/or in internal and external databases. If there are any determined issues discovered, an alert of the issue found is embedded in the response or the determined issue may be automatically corrected. The alert may provide an instruction on how to rectify the issue to a healthcare provider administrative user. The formatting and structure of the eligibility response may be normalized such that message segments relating to a same service type are grouped together, providing a consistently formatted normalized response. Accordingly, an end user may be able to more easily find information in the normalized eligibility response.