Ultera/P8 for Pre- and Prior Authorizations

Business Challenge
Compliance mandates require insurers to secure, control and monitor operational processes and confidential content including: authorization requests, prior benefit determinations, pre-admission certifications and related medical records. Reliance on manual, paper-based business processes hampers an insurers’ ability to meet customer demands and compliance requirements, as well as respond to new product introductions and changing market dynamics.

Paper-based manual processes delay processing times; documents are easily lost, resulting in duplicate submissions. Manual routing associated with multi-level review of denied authorizations can cause further delays. This impedes the insurers’ ability to meet Service Level Agreements (SLAs), which can have a significant impact on an the insurer’s bottom line.

Upgrading inflexible business processes requires significant time and effort. As such, today’s insurers need out-of-the-box solutions that can automate pre- and prior authorizations and support member self-serve access to necessary services. These solutions must enable insurers to quickly create and modify business processes and support outsourced and offshore operations, while meeting SLA and regulatory compliance requirements.

Solution
IPD’s Ultera/P8 for Pre- and Prior Authorizations captures, catalogs and stores all member and provider transactions received by paper, fax, e-mail or via a self-service portal, in an IBM Enterprise Content Management (ECM) repository, eliminating the potential for lost documentation. An optional business rules engine integration identifies and eliminates duplicate authorization requests without any staff involvement.

Ultera/P8 for Pre- and Prior Authorizations performs initial membership validation, applies configurable business rules to automate work distribution and automatically creates and distributes electronic work items to the next step in the business process. When additional external information is requested and received, Ultera/P8 for Pre- and Prior Authorizations automatically associates it with the appropriate authorization and sends an alert to the staff member assigned to the work.

Staff assigned to first, second and subsequent levels of review perform work within specialized Ultera/P8 for Pre- and Prior Authorizations interfaces that are specific to their responsibilities. These interfaces prioritize work based on SLA requirements, supply all the information needed to approve or deny requests and immediately reassign authorizations requiring additional review.

Working solely within these interfaces and without need to reference host systems, staff members can select status codes to complete each request or automatically go to the next step in the process. Additionally, Ultera/P8’s for Pre- and Prior Authorizations optimized processing interfaces support other tasks, including integrated letter generation for authorization approvals and denials that require written responses.

Value Proposition
Designed and built by insurance industry experts and based on real-world customer requirements, Ultera/P8 for Pre- and Prior Authorizations is scalable from the smallest to largest numbers of users across geographically dispersed operations, offering insurance-specific capabilities to improve performance; comply with SLAs and other contractual requirements; reduce administrative costs; and, respond to changing business conditions. The solution streamlines pre- and prior authorization by ensuring that member and provider requests are responded to in a timely manner, delivering a significant competitive advantage and lowering risk via process consistency.

Ultera/P8 for Pre- and Prior Authorizations interfaces increase productivity and accuracy by allowing insurance staff to work within a single, consolidated view. This enables them easy access to all of the information that is available and needed in order to process pre- and prior authorizations and enables them with the ability to view tasks in the order in which they must be fulfilled.

The solution delivers a low total cost of ownership and a compelling return on investment, with complete payback in less than 12 months. In addition, IPD clients report dramatic performance improvements and business returns, including cycle time reductions of 50 percent or more, productivity increases of better than 45 percent, and processing cost reductions exceeding 40 percent, with assured compliance, and within a fully configurable solution that is often deployed across most of the core operational areas of insurance organizations.

As an out-of-the-box application, Ultera/P8 is proven to implement faster and with lower risk than custom- and integrator-built solutions. Many IPD clients required no coding effort whatsoever to implement solutions to meet their exact requirements.