AGI.do

Processes

What will AGI do for Manage provider referral?

A provider submits a referral request for a member to receive specialized medical care or services.

Trigger
A provider submits a referral request for a member to receive specialized medical care or services.
Outcome
The referral request is adjudicated and the final determination is communicated to the requesting provider, receiving specialist, and member.

The work itself

Grounded Work Profile

Measured by

  • Referral Turnaround TimeprocessProfile
  • Auto-Adjudication RateprocessProfile
  • Out-of-Network Referral RateprocessProfile
  • Referral Denial RateprocessProfile

Key steps

  • Receive and log the referral request from the providerprocessProfile
  • Verify member eligibility and active plan benefitsprocessProfile
  • Review the request against clinical guidelines and network tier constraintsprocessProfile
  • Determine approval, denial, or modification of the referralprocessProfile
  • Assign an authorization number to approved referralsprocessProfile
  • Transmit the referral decision to the providers and the memberprocessProfile

How AGI delivers it

Four ways AGI delivers for Manage provider referral

  • 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 Manage provider referral connects

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Go deeper

Explore Manage provider referral

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