Prior Authorization
Ensuring smooth Revenue cycle
Managing Revenue Cycle
The Prior Authorization tab within Revenue Management is a specialized tracking tool that monitors the utilization of authorized services. It cross-references scheduled and performed tasks against the member's insurance limits to ensure your agency stays within the approved budget and unit counts.
This dashboard lists all prior authorizations, as received for the selected month, for your client population. For NJ Support Coordination companies, the prior authorization entries are matched with an appropriate task and its associated monitoring tool. The companies can access associated MT and can also list its status. The dashboard is built using a data grid and honors all functionality described here.
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1. Header & Date Controls
Date Range Selector: Allows you to view authorizations active within a specific window (e.g., 12/01/2025 β 12/31/2025). Use the [ο ] and [ο‘] arrows to navigate between billing periods.
SELECT FILEABLE CLAIMS: A shortcut to move validated entries directly into the billing queue.
π 2. The Authorization Table
This table provides a high-density look at the "Authorization Health" for every service being delivered.
Member & Identification
DDDID & Patient Name: Identifies the recipient (e.g., Andre Fuego Mandana Maya).
Medicaid ID: The primary insurance identifier used for the claim.
DDD Tier: Displays the member's budget tier (e.g., Tier F), which often dictates the available service rates.
Service Details
Prior Auth Number: The specific approval code received from the payer (e.g., 4552058649).
Proc Code & Modifier: The billing code (e.g., H2015 HIU4).
Task Type: The human-readable name of the service, such as CBS Acuity Visit or Supported Employment - Individual.
Task Start/End Date: The specific week or period covered by these units.
Financials & Units
Auth Units / Amount: The total number of units and dollar value approved by the payer for this period.
Expected Amount: The revenue projected based on the Billing Rate.
Charge Identified: Indicates the status of the authorization match (e.g., Partial Auth).
π 3. Real-Time Unit Tracking
The most critical feature of this tab is the unit countdown, which prevents over-servicing and claim denials:
Units Used: Tracks how many units have already been documented through Timesheets or the SDR.
Units Remaining: Shows exactly how many units are left for the current Task End Date.
Total Units Remaining: Provides the grand total of remaining units for the entire multi-week or multi-month authorization.
π οΈ 4. Navigation Icons
The top right icons allow you to toggle between different financial views:
Pie Chart: Financial Summary
List Icon: Accounts Receivable
Checkmark Icon: Claims
Sync (π): Refreshes the table to pull in the latest Scheduler updates.
Utilization Warning: If the Units Remaining column reaches
0, any further sessions scheduled for that member will be unbillable. Use this page to identify members who are close to exhausting their benefits so you can request a plan renewal or a "Prior Authorization Extension" from the state.
The dashboard has the following columns.
DDD ID
Patient Name
DOB
Medicaid ID
Prior Auth (number, when available)
Proc Code
Diagnosis Code (key validation if your payer is Medicaid)
Task Start Date (of the matched task, where available)
Task End Date (of the matched task, where available)
Auth Units (from Prior Auth file, where available)
Auth Amount (from Prior Auth file, where available)
Total Charges (from Prior Auth file, where available)
Task Title (of the matched task, where available)
Task Type (of the matched task, where available)
Task Date (of the matched task, where available)
Status (matching of prior auth entry, where available)
Claim Status (where available)
MMT (link to the MT associated with the matched task, where available)
MT Status (associated with the matched MT, where available)
Error Code (where available)
Error Description (where available)
Users can upload their monthly authorization file for populating this dashboard, and also improving the quality of the accounts receivable, as well as the revenue cycle.
Users can select, download, and print any combination of the data, as needed.
Data flows into the Revenue cycle
The Project page, often referred to as the Service Delivery Record (SDR), is the operational heart of the platform. It is where you track the actual execution of authorized services. This page acts as the "bridge" that turns a scheduled visit into a billable line item by verifying that the work was actually performed.
π 1. Project Overview & Hierarchy
The SDR page organizes work into Projects, which typically represent a client's Individual Service Plan (ISP) or a specific authorization period.
Project Name: Usually named after the member and the service type (e.g., Justine Ayroor - Community Based Supports).
Member Link: Each project is directly tied to a Customer profile, ensuring all data is centralized.
Date Range: Defines the authorized window for the service (e.g., Jan 1, 2026 β Dec 31, 2026).
π 2. Tracking Task Execution
Within each project, you can view the specific tasks being performed by your field staff. This is where visit data is validated before it hits your billing ledger.
Task Metadata
Task Type: The billable service code (e.g., Individual Supports).
Status: Displays whether the work is Not Started, In Progress, or Completed.
Time Tracking: Shows the actual duration of the visit as recorded by the fieldworkerβs Check-in/Check-out.
The "Data Trail"
Before a project entry is considered "Billing-Ready," it must pass through these quality checks:
Location Tracking (EVV): The system verifies the GPS coordinates of the mobile check-in against the client's home address.
Activity Logs: You can view the specific notes, photos, or digital signatures captured during the visit.
Linked Forms: Any required documentation (like an ECF-TME) completed during the session is permanently attached to the task record.
Monitoring Tools (MT): The system tracks and verifies for NJ Support coordination companies if an appropriate MT document has been completed and approved.
π οΈ 3. Managing and Approving Records
Administrators use the SDR page to audit performance and "green-light" sessions for payment.
Reviewing Notes: Click on a completed task to read the Case Notes and verify clinical accuracy.
Approving for Billing: Once a supervisor confirms the session is accurate and documented, it moves into the Accounts Receivable tab.
Correcting Errors: If a fieldworker forgot to clock out, admins can manually adjust the time here to ensure the record reflects reality.
π 4. How Data Flows to Billing
The SDR page is the final filter for your revenue cycle:
Scheduler: A visit is planned.
Mobile App: The fieldworker delivers the service and records time/notes.
SDR / Projects: The manager reviews the record for compliance and "completes" the task.
Accounts Receivable: The validated data is automatically converted into a dollar amount for the monthβs ledger.
Audit Tip: Use the Filter tool on the Projects page to find "Completed" tasks that are missing Forms. Fixing these here prevents "Missing Documentation" denials on the Claims page later.
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