Building Real-Time Prior Authorization and Claims Operations Across OP and IP Care
A multi-specialty healthcare provider is working with elsai to establish a unified prior authorization and claims workflow that improves payer visibility, submission readiness, authorization utilization tracking, and operational control across outpatient and inpatient care.
Faster Authorization & Claims Package Preparation
Reduction in Clinical Documentation Review Effort
Faster Audit Preparation
Overview
A multi-specialty healthcare provider manages a high volume of outpatient and inpatient authorizations across multiple clinical specialties. Its teams coordinate prior authorization and claims activity through EHR and HIS modules, payer portals, spreadsheets, and phone-based follow-up.
The organization wanted to create a consistent operating model across specialties while maintaining human control over authorization and claims decisions. The scope also required on-premises deployment, real-time payer visibility, independent tracking of multiple services within a visit, and better visibility into whether approved authorizations ultimately convert into delivered services.
Business Challenge
The organization sought to reduce the administrative effort required to manage prior authorization and claims activity across outpatient and inpatient care while improving submission quality, payer visibility, and revenue tracking.
Coordinators and utilization management teams relied heavily on disconnected systems and manual follow-up. Each specialty carried different payer requirements, documentation rules, and timelines, while leadership lacked a single operational view of case status, exceptions, authorization utilization, and revenue exposure.
01
Fragmented authorization and claims tracking across payer portals, spreadsheets, and clinical systems limited real-time case visibility.
02
Approved authorizations were tracked, but whether the approved service was actually utilized was not, creating a blind spot in revenue realization.
03
Multiple services within the same patient visit required separate authorizations, but one service could mask the status or delay of another.
04
Payer documentation requests and physician clarification depended on manual follow-up, increasing the risk of delayed responses and avoidable rework.
05
Authorization histories had to be reconstructed across systems for audits and disputes, increasing operational effort and governance risk.
elsai Solution
elsai proposed a governed prior authorization and claims workflow across the provider's existing healthcare ecosystem, covering all clinical specialties across outpatient and inpatient care.
The platform is designed to operate entirely within the provider's on-premises environment. Existing EHR, HIS, payer, and communication systems remain in place, while coordinators, utilization management staff, and physicians retain authority over critical decisions.
The elsai solution enabled:
• Structured case intake for outpatient referrals, service orders, and inpatient admission packages from approved on-premises sources.
• Independent service-level tracking so every ordered service receives its own authorization status while remaining linked to the overall patient visit.
• Insurance and authorization verification using configurable specialty and payer rules for coverage, network eligibility, and authorization requirements.
• Clinical documentation validation across diagnosis information, ICD and CPT codes, supporting evidence, medical necessity, and specialty-specific requirements.
• Real-time payer status tracking across approved, pending, denied, and Additional Information Request states as payer responses are received.
• Structured payer and physician exception handling, including retrieval of requested clinical evidence and targeted clarification questions when documentation is incomplete or ambiguous.
• Authorization utilization tracking to distinguish approved and utilized services from approved but not utilized services, including the reason for non-utilization.
Business Impact
Faster Authorization and Claims Package Preparation
Standardized generation of payer-ready documentation is expected to reduce the time spent manually compiling forms, clinical evidence, and supporting attachments by 60–80%.
Reduced Clinical Documentation Review Effort
Continuous specialty-aware validation is expected to reduce repetitive manual completeness checks and clinical document review effort by 50–70%.
Less Manual Case Tracking and Follow-Up
A centralized operational view across specialties, payers, and care settings is expected to reduce spreadsheet and email-driven tracking activity by 60–80%, allowing staff to focus more time on exceptions.
Improved Revenue Visibility
Authorization utilization tracking gives operations and revenue teams a direct view of approved services that were delivered versus those that were not, including reasons such as patient no-show, service unavailable, patient declined, or authorization expiry.
Faster Identification of Payer Exceptions
Additional Information Requests can be detected as they are received, allowing supporting clinical evidence to be retrieved and routed without waiting for repeated manual portal checks.
Stronger Operational and Audit Readiness
A continuously maintained and exportable authorization history is expected to make audit preparation 90%+ faster than manually reconstructing case records across disconnected systems.
Better Management Visibility
Live operational dashboards are expected to reduce manually prepared reporting effort by 80–90%, giving leadership direct visibility into case aging, workload, exceptions, utilization, and pipeline status.
The elsai Advantage
• Existing EHR, HIS, payer, and clinical systems remain in place.
• Outpatient and inpatient workflows operate through one governed operating layer.
• Specialty and payer rules can be configured without rebuilding the workflow for each department.
• Critical authorization and claims decisions remain under qualified human review.
• Approved-service utilization and revenue exposure become visible within the same workflow.
• Every operational decision, exception, and action remains traceable through ARMS.
