Before the clinical question comes the routing question.

Start from the coverage result. Five things decide where a request goes and what it has to contain, and Integrex Health answers all five before it is submitted: who carries the risk for the plan, which state's rules govern it, who actually reviews the request, the submission itself, and the payer's own policy.

The request goes to the right reviewer the first time, under the right rules, with the right requirements attached.

A fully insured plan is one the insurer pays for, so the insurer's rules apply. A self-funded plan is paid for by the employer, and the insurer or an administrator only processes it, so the employer's plan rules apply. Nothing on the card says which. Integrex Health identifies the funding type before the request goes out.

For a fully insured plan, situs is the state where the policy was issued, and that state's rules decide the requirements and the deadlines that apply to the authorization, to the claim and to any appeal. It is not always the state where the patient lives. Integrex Health identifies the situs so the request is built to the rules that will actually be applied.

The entity that reviews a prior authorization is often not the payer on the card. Many plans hand the review to a utilization management vendor, and a request sent to the payer instead comes back as an administrative rejection. Integrex Health locates the entity that reviews the request and routes it there.

Integrex Health submits prior authorization requests as the standard electronic transaction (X12 278) to hundreds of payers, with more than 11,000 submitted to date, for payers including Florida Blue and Meritain Health.

Millions of pages of payer policy documents, collected from public, private and internal sources, tell the request what each payer requires for the procedure in question, so it goes out complete.

Whether the plan is commercial, government or Blue, requests reach the right reviewer under the right rules, so fewer come back needing information that was knowable at the start. Staff time moves from resubmission to the cases that need a person. In the Orchestration Layer this is Route and Authorize, decided by what Classify found.