Processes

What will AGI do for Conduct CMS authorization?

A healthcare provider submits a prior authorization request for a medical service, device, or prescription drug covered under a Medicare or Medicaid plan.

Trigger
A healthcare provider submits a prior authorization request for a medical service, device, or prescription drug covered under a Medicare or Medicaid plan.
Outcome
The request is formally approved, modified, or denied according to CMS regulations, with the decision logged and communicated to the provider and member.

The work itself

Grounded Work Profile

Measured by

  • Turnaround Time ComplianceprocessProfile
  • Denial Overturn RateprocessProfile
  • Cost Per Authorization ReviewprocessProfile
  • First-Pass YieldprocessProfile

Key steps

  • Receive the authorization request and supporting clinical documentation.processProfile
  • Verify member eligibility and specific CMS plan coverage details.processProfile
  • Evaluate clinical data against CMS National and Local Coverage Determinations (NCDs/LCDs).processProfile
  • Route complex or edge-case requests to medical directors for specialized review.processProfile
  • Record the final authorization decision and update the core claims system.processProfile
  • Issue standardized decision notices and appeal rights to the provider and member.processProfile
  • Submit required authorization data and compliance reporting to CMS systems.processProfile

How AGI delivers it

Four ways AGI delivers for Conduct CMS authorization

  • Services-as-Software

    Get the professional outcome delivered as software, priced on results, not headcount.

    Services.do
  • Autonomous Agents as digital employees

    Hire a digital employee that does the job under earned, supervised autonomy.

    Agents.do
  • Business-as-Code

    Encode how your work runs, once, as software that executes itself.

    Platform.do

Value flow

How Conduct CMS authorization connects

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