Track authorizations and review patient estimates

Open Insurance > Authorizations. The page heading is Authorizations & estimates. These steps apply to workspaces with Insurance enabled. Workspace owners, administrators, staff, and editors can prepare this work.

The page has three tabs: Authorizations, Patient estimates, and Assistance drafts.

Record an authorization decision

You need the patient policy, provider, service scope, and payer decision evidence. Submit the authorization request through the payer’s supported channel, then record the result here.

1. Select Record authorization.
2. Choose the connection, patient policy, and rendering provider. Enter the service type and procedure code when applicable.
3. Select the Payer decision. Keep the requirement unknown until you have evidence for another status.
4. Enter the authorization number when approved, the start and end dates, and the authorized amount and unit type.
5. Record the payer reference and decision evidence. Add the next action and decision due date when needed.
6. Select Save decision.

The record appears under Authorizations. It shows the decision, service scope, dates, and reserved and consumed units. Use Update decision when you receive new evidence.

Reserve or consume authorized units

1. Select Manage usage on the authorization.
2. Choose the visit and operation: Reserve for visit, Release reservation, or Record completed service.
3. Enter the units and select Save usage.

The workspace checks the visit against the authorization’s policy, provider, service, dates, and remaining units. Recording consumption also requires a completed visit. If a visit-status control is unavailable, ask your workspace administrator before recording consumption. Resolve scope or unit errors before saving, and release reservations for visits that will not use them.

Calculate a patient estimate

First, add the visit in Overview and obtain a current successful payer response.

1. Open Patient estimates.
2. Under Calculate estimate, select the visit and Payer response.
3. Select the applicable Benefit evidence. Review the service, individual coverage level, network, and benefit period.
4. Enter the Allowed amount and its source. Enter the provider network and supporting evidence.
5. Select the cost-sharing calculation and record any assumptions for the reviewer.
6. Select Calculate for review.

The estimate displays the calculation or the missing inputs under Needs review. The calculation requires applicable out-of-pocket evidence, plus the copay, deductible, or coinsurance evidence for the chosen method. Missing or conflicting benefits leave the patient amount unresolved.

An estimate does not guarantee payment. A returned zero-dollar benefit remains a zero-dollar value; Not returned means evidence is missing.

Approve and record delivery

1. Open Calculation and source inputs and View payer evidence on the estimate.
2. Resolve any review reasons. Calculate a new estimate when the source information changes.
3. For a complete draft, select Approve estimate.
4. After delivering an approved production estimate, select Record delivery. Choose the channel, enter the recipient or delivery reference, and select Record delivery.

Recording delivery saves the delivery history. It does not send a portal message or place a phone call. If the source changes before approval or delivery, review a new estimate with current evidence.

Prepare an explanation or appeal draft

Open Assistance drafts. Select New draft. Choose a benefit explanation or staff-authored appeal draft. Choose the payer response or claim, select the retained evidence, and enter the appeal text when applicable. Select Save draft for review.

Read the draft and its evidence before selecting Approve reviewed draft. Approval records the review; it does not submit an appeal or deliver the text to the patient.