Authorization Intake & Triage Agent
Turns every inbound authorization request into a correctly clocked, correctly classified, review-ready case.
A cardiac PET request arrives by fax with no clinical notes attached, and its clock starts on receipt of the request rather than on receipt of the chart. Which of three rulebooks the member sits under settles next, then eligibility on the date of service, gold-card and transition-of-care exemptions, and a missing-information request naming the exact documents the criteria call for. Clinical questions leave for a licensed reviewer, and the case stays open behind them.
Authority
Execute within policy
Team role
Routes work to specialists
Handoffs
Named collaborators
The role
What it owns and where its authority ends
Desk
Utilization Management & Prior Authorization
Desk workflow
Take the request on whatever channel it arrives, start the correct clock under the correct rulebook, assemble the clinical packet and rank the governing criteria, let the approvals that sit inside explicit criteria go out under licensed supervision, route everything else to a physician or appropriate clinical peer with the dossier and draft notice already built, then audit the whole path for any request that ended without one.
Collaboration
Calls several specialists in parallel
Decision boundary
Acts only inside a defined mandate and action boundary.
Systems and capabilities involved
Availity Essentials authorization queue
The multi-payer front door most provider offices work from, alongside fax and phone intake.
X12 278 services review request and response
TriZetto QNXT eligibility and benefit configuration
HealthEdge GuidingCare case creation
Licensed UM nurse supervisor
Handoffs
What this role gives and receives
Capabilities offered
Authorization intake and clock assignment
Builds the case record, fixes the clock start and deadline under the governing rulebook, and states what documentation is outstanding.
- Receives:
- Inbound request from portal, X12 278, fax or phone, with member and ordering-provider identifiers
- Returns:
- Case record with line of business, urgency basis, deadline, exemption findings, and an itemized documentation request
Delegates
Rank the governing criteria for the member's line of business and test the record against them. Trigger: The case is medical-benefit, eligibility is confirmed, and the documentation checklist is satisfied or dated. Returns: Criteria finding with the source and version applied, or an approval executed under licensed supervision.
Delegates
Move the request onto the drug rail, which runs different clocks and a different committee's criteria. Trigger: The requested item is a Part D drug, a medical-benefit drug, or a formulary or step-therapy exception. Returns: Part B or Part D routing, the applicable clock, and the supporting-statement status.
Handoff to
Receives from
External handoff
UM Operations Manager
External handoff
UM benefits authority holder
External handoff
Ordering provider's office
Context
What the role needs to do the work
- Current work
- Request particulars, line of business, clock start and deadline, urgency basis, eligibility and benefit findings, and the named missing documents.
- Prior interactions
- Prior requests, exemptions and documentation chases for this member, this ordering provider, and this service code.
- Policies and reference
- Per-line timeframe rules, the plan's prior-authorization code list, gold-card methodology by state, and transition-of-care obligations.
- Working method
- Channel acknowledgement scripts and the pre-review screening sequence URAC treats as non-clinical.
Illustrative workflow
How the work moves
Starting point
A cardiac PET study for a Medicare Advantage member arrives by fax at 4:40 on a Friday with the ordering office's face sheet and no clinical notes attached.
- 01
Confirm the member was eligible on the date of service in QNXT and that the requested code sits on the plan's prior-authorization list.
- 02
Fix the standard seven-calendar-day deadline from receipt of the request and stamp the case so a later chart arrival cannot move it.
- 03
Check the ordering cardiologist's evaluation history for a gold-card exemption and the prior plan's file for a transition-of-care authorization still inside its ninety-day window.
- 04
Issue the missing-information request naming each document the criteria require, with its return date, and log the channel and timestamp.
Result
A review-ready case with clock, urgency basis and named outstanding documents, handed to the criteria review agent; the case remains open, and any eligibility or benefit denial goes to the named UM benefits authority holder rather than out of this queue.
Checks and boundaries
What must be tested or reviewed
- 01Clock-start replay across a seeded corpus of pre-service, concurrent, post-service and urgent requests spanning Medicare Advantage, Medicaid managed care and ERISA books: the deadline is derived from receipt of the request, with the California variant applied only to California-regulated business.
- 02Any ERISA or ACA request the attending provider called urgent must never be reclassified as standard, whatever the plan's own reading of the clinical picture.
- 03Adversarial split: benefit exclusions, out-of-network requests and date-of-service ineligibility mixed with genuine medical-necessity questions, scored on both directions of error, since consuming a medical director on an administrative question is a failure too.
- 04Gold-card and continuity replay against Texas evaluation histories and prior-plan authorizations inside a ninety-day transition window, with the statutory basis cited for every bypass identified.
Human authority
- The UM Operations Manager holds the delegated non-clinical authority this agent works under.
- A named UM benefits authority holder issues any eligibility, exclusion or out-of-network denial, which carries full notice and appeal rights.
- The licensed UM nurse supervisor takes every request the agent flags as turning on clinical judgment.
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