MRI prior auth
Clinical packet ready
Workflow Use Case
Prior Auth & Payer Ops
Reduce manual payer work by combining real-time eligibility and benefits checks — in-network status, deductible, copay, coinsurance, and out-of-pocket maximum — with prior auth workflows, portal automation, and follow-up in one operating flow.
Last updated:
Real-time eligibility, in-network status, deductible, copay, coinsurance, and out-of-pocket exposure surface before scheduling
Browser automation handles repetitive payer portal work
Aging and renewals stay visible before revenue is at risk
Operational picture
Payer work with less swivel-chair effort
Gather the packet, verify real-time eligibility and benefits — deductible, copay, coinsurance, and out-of-pocket maximum — submit or update through payer workflows, and keep status visible across aging and renewals.
Signals
Real-time eligibility feed
Payer portal
Payer call follow-up
Eligibility check
Deductible not yet met · coinsurance returned
Expiring auth
Renewal window open
Portal navigation
Status notes captured
Aging and renewal alerts
What Calvient handles
The real work inside this workflow
These are the operational motions the system has to coordinate well if the workflow is going to move cleanly.
Work queue
Real-time eligibility and benefits work intake
Bring real-time eligibility, in-network status, deductible and out-of-pocket exposure, copay and coinsurance lookup, auth preparation, payer responses, and renewals into one queue with clear ownership.
Packet prep
Submission readiness and completeness
Check that clinical notes, CPT and HCPCS codes, insurance details, place of service, medical necessity context, and supporting records are present before the case goes out.
Browser agent
Portal automation where APIs do not exist
Use browser workflows to submit, check status, capture reference numbers, and update case notes without repetitive staff clicks.
Aging view
Status follow-up and renewal control
Track which authorizations are pending, denied, expiring, or aging by payer so follow-up stays proactive.
How it works
Structured execution from trigger to closure
The workflow should move because the system keeps state, ownership, and next action visible at every step.
01
Gather the required packet
Collect insurance details, clinical notes, CPT or service context, and any supporting documentation needed by the payer.
Cases are not pushed into payer workflows half-complete.
02
Verify coverage and patient financial responsibility
Run real-time eligibility and benefits verification to confirm in-network status, remaining deductible, copay and coinsurance amounts, and out-of-pocket maximum exposure. Surface prior-auth requirements, patient cost share, and the inputs needed to issue a Good Faith Estimate under the No Surprises Act before scheduling.
The team knows whether the case can proceed, what the patient is likely to owe, and what evidence is still required.
03
Submit or update through payer workflow
Use portal automation, structured forms, or payer calls to move the case through the required operational path.
Submission status, reference numbers, and evidence are captured in the record.
04
Track aging, follow up, and renew
Keep pending cases moving, resolve denials or missing items, and start renewals before the authorization expires.
High-burden payer work is visible and manageable instead of reactive.
What operators see
Product views that move the workflow forward
These are the working surfaces that keep the queue understandable, actionable, and measurable.
Tasks
Payer work queue by next action
Staff can sort by eligibility, packet prep, submit, follow-up, denial, or renewal instead of working from disconnected payer lists.
CT auth request
Clinical packet ready to submit
PT eligibility check
Deductible remaining unclear · coinsurance not returned
Sleep study renewal
Expires in 5 days
- Owner and SLA by payer case
- Missing artifact flags
- Submit versus follow-up separation
Browser agent
Portal work with activity captured
Operators can see what the agent submitted, where it clicked, and what payer response came back.
Login + submit packet
Availity flow completed
Status recheck
Pending medical review
Exception flagged
Portal requested new clinical note
- Reference numbers recorded
- Portal outcomes logged
- Exceptions routed to staff review
Reporting
Aging and payer performance view
Managers can see where cases are piling up, which payers create the most rework, and where renewals are slipping.
Payer A
Longest turnaround this week
Payer B
Highest first-pass approval rate
Renewals
3 cases entering risk window
- Aging by payer
- First-pass completeness
- Rework and denial patterns
Workflow Views In Product
In Product
Auth work queue
Queue grouped by submit, follow-up, denial, and renewal states.
In Product
Browser automation activity
Payer portal task detail with logged actions and confirmation note.
Special Agents
Special Agents for this workflow
These agents are useful because they handle the repetitive middle of the workflow while leaving sensitive or ambiguous decisions with staff.
Payer portal submitter
Handles repetitive browser-based submission work and captures what happened for the record.
Trigger
Cases ready for payer portal submission or status review
Actions
- Navigate payer workflow
- Submit required fields and attachments
- Capture confirmation or status response
Handoff
Escalates portal exceptions, denials, or missing-data prompts to the auth team.
Auth status caller
Places structured follow-up calls when portal visibility is weak or payer rules demand phone confirmation.
Trigger
Aging cases or payers that require voice follow-up
Actions
- Call with case details ready
- Log structured outcome notes
- Schedule next follow-up step
Handoff
Routes unresolved or contradictory payer responses to the case owner.
Expiring auth renewal agent
Keeps expiring authorizations from becoming avoidable scheduling or billing problems.
Trigger
Cases approaching expiration or scheduled services beyond current auth window
Actions
- Open renewal work early
- Collect needed packet updates
- Queue or run payer renewal follow-up
Handoff
Escalates only when service dates, payer rules, or clinical context require human review.
Operational channels
The workflow moves across multiple channels without losing state
Payer operations run across portals, calls, documents, and internal queues. Calvient keeps the work in one operating loop.
Fax
Text
Phone
Browser
Forms
EHR / integrations
Fax
Payer responses, request letters, and supporting clinical documents
Text
Patient outreach when updated insurance or scheduling coordination is needed
Phone
Payer status calls, peer-to-peer coordination, and escalation work
Browser
Portal submission, status checks, evidence uploads, and renewal work
Forms
Structured auth packet prep and internal readiness checklists
EHR / integrations
Clinical note retrieval, chart context, and downstream scheduling coordination
Teams that use this
Deployment usually spans more than one team
This workflow usually crosses prior auth, revenue cycle, scheduling, and nursing review. The system needs to keep all of them on the same case state.
Prior Auth
Revenue Cycle
Authorization Nurses
KPIs / outcomes
Measure the outcomes that matter
The right operating system should make these measures easier to see, easier to improve, and easier to explain to leadership.
KPI
Auth turnaround time
How long authorizations take from work start to usable approval or resolution.
KPI
First-pass completeness
How often the first submission goes out without preventable missing items.
KPI
Rework rate
How often staff must reopen a case because information, status, or follow-up was incomplete.
KPI
Aging by payer
Which payer queues are creating the most delay and operational burden.
KPI
Patient cost-share accuracy
How often deductible, copay, coinsurance, and out-of-pocket figures presented to staff and patients match the payer of record at the time of service.
Related use cases
Explore adjacent workflows
Referral Management
Centralize inbound and outbound referral work, track status, request missing information, and move patients forward.
Operational Visibility & Reporting
Show queue health, backlog, turnaround time, productivity, and automation/reporting metrics.
Intake & Triage
Capture inbound work from fax, email, forms, and other channels, classify it, and route it to the right workflow.
Frequently Asked Questions
Does Calvient verify the patient deductible and out-of-pocket maximum before the visit? +
Yes. Calvient runs real-time eligibility and benefits verification to confirm in-network status, remaining deductible, copay and coinsurance amounts, and out-of-pocket maximum exposure. The values surface in the work queue so staff and patients can resolve cost-share questions before the appointment instead of at check-in.
Can Calvient help with Good Faith Estimate compliance under the No Surprises Act? +
Calvient surfaces the inputs required to issue a Good Faith Estimate — CPT and HCPCS codes, place of service, in-network status, patient cost share, and deductible status — and flags scheduled services where a Good Faith Estimate is required under the No Surprises Act. Staff approve and deliver the estimate through your existing patient communication workflow.
How does Calvient handle copay and coinsurance lookup for inbound referrals? +
When an inbound referral arrives, Calvient queries the patient's payer in real time for eligibility, in-network status, copay, coinsurance, deductible remaining, and any prior-auth requirements. Coverage mismatches and unmet patient responsibility are flagged before the referral is scheduled so the team can reach out with accurate cost expectations.
Can Calvient draft appeal letters automatically? +
Yes. Calvient drafts appeal letters using denial reason codes, clinical documentation, and payer-specific requirements. Staff review and approve the draft before submission rather than writing each letter from a blank page.
How does rework get routed after a denial is identified? +
Calvient assigns denied claims to the appropriate team or individual based on denial type, payer, or dollar threshold. Routing rules are configured during implementation and can be adjusted as volume patterns change.
Does Calvient replace our billing team or support them? +
Calvient supports the billing team by handling the repetitive, high-volume parts of denial management and rework routing. Staff focus on decisions, exceptions, and payer escalations rather than administrative triage.