Prior Authorization Request

[Former Member]

Hi All,

How to do <b>Prior Authorization Request</b> webservice scenario through XI - BPM?

Scenario: Hospital sends the Patient details and drugs info..to Insurance company. Insurance company has rights to Accept or reject the request. If it is rejected then it should provide the rejected info as a response. Insurance company activities are human interaction part.

Any idea, How to go about this type of scenario using BPM? Do we need to use EP(Enterprise Portal) for human interaction part(To accept/reject the request)

Regarsds

Sara

Message was edited by:

Sara D

[former_member192892]

Sara,

I don't see this scenario happening as a syncronous one because the response is dependant on user interaction. So a work around i see is to separate two scenarios.

1st would be a soap sender to JDBC ,where you'll store the data in database tables.

2nd would be to take updated data from this table back as response.

The data in the tables will be manipulated using an EP application..

[former_member192892]

I thought further on this,

May be this can be achieved. Of course you'll need a mechanism to catch the user response of rejection or acceptance and store somewhere like in a table.

Then you can have two receive steps in your BPM, one for the soap sender and another for the database updation....

May be possible

[Former Member]

Hi Varun,

Thanks for your suggestions...Very useful ideas...

Regards

Sara

[Former Member]

Hi All,

Is it possible to do only with XI?

Regards

Sara

[Former Member]

Sara,

Is ur Insurance company an R3 system or a legacy system?

If it is a R3 syrtem then based on the response, from the R3 which could b an accept or reject, an email could b triggered.

A fork step could b used, after the response and an alert could b triggered.

would b very similar for legacy too..

regards,

Vishal

[Former Member]

Hi Vishal,

Thanks for your good suggestion.

Insurance company is a legacy system. Actually, I am doing sample demo.So, anything will be fine.

Webservice -> XI -> Mail (Synchronous).

1. The webserive request will be sent to Insurance company thro' XI using mail Adapter. (Webservice -> XI -> Mail)

2. Insurance company will check the drug description and they will send the approval status to the Hospital via XI. ( Mail Adapter -> XI -> Webserice)

I should keep some sleep time to get the response back.

Is the entire above mentioned approach is correct? Is it possible to do with XI (only using XI, but not with EP and so and so.) Please correct me, if I am wrong with this approach.

Regards

Sara