Automated Real-Time Prior Authorization:

Benefits, Barriers, Informatics In Context’s Value Proposition


  1. Only effective method to contain costs and prevent unnecessary treatment, over-utilization, and misuse
  2. A scalable, real-time and automated PA process allows utilization management to expand to higher volume and lower cost procedures
  3. If done correctly the first time, prior authorization prevents denials, re-adjudication of claims, impactsreprocessing rates, eliminates medical review, and avoids penalties for recalculation of member and patient liability
  4. Quicker responses means faster time to patient scheduling and treatment, resulting in improved outcomes and increased customer (patient and member) satisfaction


  1. The current prior authorization process is manual, proprietary, administratively burdensome, and very costly per transaction
  2. Adjudication costs per transaction are very expensive, requiring back office staff for processing, clinical staff to handle denials and appeals, and FTE’s to handle incoming call center volumes
  3. Current PA process is not scalable. Payers mainly outsource adjudication of highest cost procedures to specialty benefits companies, which adds ever more cost per transaction


  1. IIC makes EDI 278 transactions useful, not simply compliant with ACA mandate
  2. Adjudicate majority of prior authorization requests without human intervention
  3. Automate any and all clinical guidelines – CMS, Custom, MCG, InterQual, etc.
  4. Guidelines are editable by payers when updates or changes are needed
  5. Using EDI 278l, a uniform and standardized clinical workflow can be implemented for all providers within the payers’ network
  6. An order of magnitude of time and cost savings is achieved by maximizing automation and increasing administrative efficiency
  7. Quality of care delivered at the right time for the right reason is based on enforcing defensible evidence-based guidelines
  8. Scale utilization management to control over-utilization and misuse
  9. 278 Authorization Engine is configurable to meet health plans’ authorization criteria
  10. Dramatically reduces need for denials, appeals, medical review and re-adjudication of claims
  11. Value of pre-payment ties authorization claim to approval code, avoiding “pay and chase”
  12. Automated prior authorization improves timelines of overall claims adjudication
  13. Lowering internal costs allows payers to redirect limited staff without increasing their budget
  14. Advanced analytics allows system to recommend most cost-effective alternative clinical options based on best practices and evidence-based medicine
  15. Advanced analytics can be customized and applied to detect trends and patterns, such as fraud alerts, procedure selection patterns, provider submission patterns, incurred real-time costs, and much more.
  16. Clinical decision support and adherence to evidence-based guidelines is more effectively enforced from the payer side
  17. IIC consultative expertise based on real-world payer experiences for change management allows payers to avoid implementation pitfalls.